Women Veterans’ definitions of peer support: A qualitative description analysis

Abstract

Introduction:

Women are the fastest-growing subpopulation of U.S. military Veterans, yet their voices have rarely been used to explore peer support among Veterans. This study defines Veteran peer support from the perspective of women Veterans and aims to increase providers’ awareness of the value of peer support for improving Veteran mental health.

Methods:

Data were drawn from a multi-site evaluation of Veteran peer programs. Transcripts from semi-structured interviews with women Veterans (N = 25) were selected and analyzed. Guided by a qualitative description approach, the researchers used in vivo coding to capture common descriptive language used by the Veterans. Themes were drawn by the primary researcher and audited by a second researcher to increase the findings’ trustworthiness.

Results:

Women Veterans described peer support as a relationship between Veterans based on shared military experience, an understanding of military culture, and similar life challenges. Emerging themes regarding peer support included viewing peers as genuine, trustworthy friends, empathizing over shared struggles, cultivating a safe, non-judgmental, egalitarian space to discuss sensitive topics, using a non-stigmatizing, non-clinical approach, and being a source of fun and social connection.

Discussion:

Participants provided evidence that peer support is a meaningful, authentic, and accessible means of exchanging emotional and concrete assistance for women Veterans. Mental health providers and program developers working with women Veterans need to understand the importance of peer support in complementing therapy and how it can be essential for women Veterans to discuss sensitive topics such as sexual assault or harassment they experienced in the military.

Lay Summary

This study examines peer support among women who served in the U.S. military. Women Veterans reported peer support to be helpful for mental health and well-being by meeting social, emotional, and concrete needs. Participants found peer support to be acceptable, non-clinical, and non-stigmatizing. Critical elements of peer support included a safe environment, someone to listen to and validate them, and the shared experience of serving as women in the military. Peer support was particularly helpful for discussing sexism, sexual assault, and trauma. Mental health providers should understand the importance of peer support for women Veterans and how it is a distinct and complementary service to clinical treatment. Peer support programs can help ensure women Veterans’ needs are considered in service delivery.

Introduction

Women are the fastest-growing subpopulation of U.S. military Veterans, making up 9% of the Veteran population (1.7 million) in 2018 and an expected 17% by 2040.¹ Women Veterans have unique experiences and challenges as women in a male-dominated warrior culture. A systematic review of women Veterans’ mental health found higher rates of disorders such as depression and comorbidities compared with men Veterans.² Peer support is well established in the mental health field and has been used to help Veterans,^3–8 yet little is known about how women Veterans view peer support.

Terminological variation (e.g., self-help, mutual help, mutual aid, mutual support) complicates the study of peer support.⁹ Penney suggests a two-category classification:¹⁰ 1) peer-developed peer support and 2) the employment of peers in existing mental health programs. Peer-developed peer support originated out of dissatisfaction with mental health treatment and in opposition to terminology such as mental health patient. Peers use their lived experiences in non-hierarchical relationships. Alternatively, peers employed in mental health organizations often work in existing psychiatric programs performing tasks similar to those of non-peers.

Solomon and Draine define peer support for mental health as an individual with a mental illness providing services to others with mental illness.¹¹ Dennis defines peer support in the more general health care context as:

[the] provision of emotional, appraisal, and informational assistance by a created social network member who possesses experiential knowledge of a specific behavior or stressor and similar characteristics as the target population, to address a health-related issue of a … stressed focal person.^{12 (p.329)}

Dennis’s definition extends beyond mental health to include wider health promotion rather than a focus on mental illness.¹²

According to Davidson et al.,¹³ a peer is a person who made improvements in their psychiatric condition and offers services to those not as far along in recovery. Peer support is not about psychiatric models or diagnosis; rather, it focuses on empathy “through the shared experience of emotional and psychological pain,” and it consists of the principles of “respect, shared responsibility and mutual agreement of what is helpful.”^{14 (p. 6)} Despite definitional variation, there are some recurring themes in peer support. It occurs between people with some shared life experiences who provide each other with empathy, understanding, support, and a sense of shared community and belonging unlike that given by a professional without a similar experience.⁹

The vast published literature on peer support has yet to fully consider women who served in the military or examine the influence of military culture on peer support. This is important, given that military and Veteran culture is distinct from society.^15–19 Coll et al. discuss how the world view of Veterans,¹⁸ affected by military culture, decreases help seeking and increases mental health stigma. Reger et al. suggest training for non-Veteran civilian psychologists working with military members to ensure ethical, culturally competent services.¹⁹

Although not always the primary focus, some noteworthy studies mention women Veteran peer support. Koblinsky et al. hosted focus groups with 29 women Veterans to elicit their opinions on how to improve mental health care services.²⁰ Among other strategies suggested, the authors found that women recommended increasing peer support programs.²⁰ Notably, women found peer programs beneficial because of being around other women Veterans, allowing for non-judgmental discussion on sensitive topics and creating camaraderie without feeling like therapy.²⁰

Another study asked women Veterans their peer support preferences for encouraging cardiovascular health.²¹ The authors found that women Veterans valued trust, behavioral goal compatibility, positive attitude, and accountability in peer groups. Similarly, one study examined Veterans’ perspectives on group peer support alongside clinical treatment of posttraumatic stress (PTS).²² Women made up about one-quarter of the sample (n = 6), and their group preferences were mixed, depending on the topic. Some women felt as though mixed-gender groups would be uncomfortable for women when talking about sexual trauma, and other women felt they would like to hear men’s perspectives on how they deal with PTS.²² Given these nuances, the current study explores the definition of peer support, focusing on the perspectives of women Veterans specifically to benefit their mental health. The guiding research question was “How do women Veterans who participate in community-based peer support programs define and describe peer support?”

Methods

This study follows a qualitative description approach,²³ using participants’ words to describe peer support. Polit and Beck define the main objective of descriptive research as “the accurate portrayal of characteristics of persons, situations, or groups.”^{24 (p. 552)} Direct description maintains closeness to the data, allowing for the participants’ words — rather than the researcher’s interpretation — to be the primary focus of attention. This method was chosen for its emphasis on a clear and straightforward description of the phenomenon.

This study is a secondary data analysis using a sub-sample of interviews with women Veterans (N = 25) purposively drawn from a larger evaluation of Veteran peer support programs in New York State. A semi-structured interview guide was used to elicit participant experiences with and perspectives on using community-based peer support programs for Veterans. Veterans with different roles in the programs — ranging from service recipients to staff to administrators — were interviewed. Despite this role differentiation, all were treated the same in data analysis because of the non-hierarchical and mutually reciprocal nature of peer support. The semi-structured approach allowed for a wide range of interview topics, with flexibility for participants to expand on areas essential to their own experiences.

Interviews were conducted in person by a member of the research team (which included both authors) and audio recorded with participants’ permission. Veterans were asked, “What does peer support mean to you?” “How would you explain Veterans’ peer support to someone who has never heard of it?” and “How would this program be different if you were paired with a non-Veteran instead of a peer?” These, and other follow-up questions, allowed participants to reflect on their unique experiences with peer support. All study procedures were approved by the institutional review board at the University at Albany, State University of New York.

Transcripts were coded in Atlas-TI software by two women researchers who are also U.S. military Veterans (one of whom is the first author). Primary, secondary, and tertiary codes were developed iteratively. Code consensus was reached through regular meetings, comparative coding, and follow-up discussion to address similarities and discrepancies. A total of 44 codes were developed, with 20 relating to peer support and the remainder capturing participants’ military experiences. Reports from relevant codes were generated, and themes were identified when data from multiple participants yielded shared content.

Results

The sample included transcripts from 25 women Veterans who served in the U.S. military. Their ages ranged from 25 to 67 years, with a mean of 57 years. Of the women, 40% (n = 10) identified as Black, Latina, or multiracial, with the remainder identifying as white. The sample spans five decades of service from 1964 to 2016, and 40% (n = 10) of the women served in a combat zone. Of the Veterans, 32% (n = 8) were program participants, meaning they were seeking services, and the remaining served in staff roles (e.g., program coordinators, outreach coordinators, peer mentors, or peer facilitators). Programs used different titles, but all staff provided peer support to participants individually or in groups, with the goal of improving Veteran mental health and well-being.

Although operationally and structurally distinct, each program delivers services to any Veteran free of charge. The only criteria for program participation are Veteran status and voluntary interest. Typical services include peer mentorship, support groups, social activities, and opportunities for prosocial community building and engagement. As is typical of peer support settings, the boundaries between staff and service recipients are fluid, minimally defined, or both. Data were organized into four themes, described next.

Theme 1: Women Veteran peer support is built on the foundation of serving as women in the military and sharing similar life challenges

Frequently, the women described peer support as an individual exchange between Veterans. This relationship was delineated further as a friend, sister, or an immediate bond. The exchange of peer support was described by one Veteran as “two people getting together, meeting, and talking. Building a friendship” (peer mentor, Army National Guard). Another Veteran stated, “As another Vet, you can talk Vet. You can have that conversation and it’s more fluid” (peer mentor, air force). The peer relationship was based on the shared experience of serving in the military and could be reminiscent of the camaraderie experienced while serving: “You both have lived that military life, so you know that experience. So, you kind of connect and you expect that teamwork, that camaraderie. That’s what you’re used to” (peer mentor, Army National Guard). Women often referenced networks of social connection and support happening in group support settings amid their peers.

Along with military service, shared experience could refer to shared difficulties, as one woman explained: “The women Veterans, they probably went through the same struggles I went through and we’re not alone in that” (outreach coordinator, navy). For example, the women could relate to managing mental health symptoms or challenges applying for benefits. One Veteran related, “I’ve been in your situation at some point. This is what I did, and this is what worked, and this is what didn’t work and, you know, maybe this will work for you” (peer mentor, air force and Air National Guard). Other shared difficulties included encountering sexism, physical injury, or psychological trauma while in the military. Struggles could also relate to transitioning from military service, such as finding employment, returning to higher education, or coping with substance use. Talking about peer services, a woman remarked, “It just offers you so many more options and provides direction and other mentors. You know, from people I’ve talked to, just … they’ve gotten jobs, they’ve gotten their lives back on track. They’ve stopped drinking” (peer mentor, air force and Air National Guard).

The Veterans emphasized that peer support happened only among those who served in the military. Referring to civilians, one Veteran remarked:

I don’t think they’ll be able to relate as much as the person that actually went through it … I feel if you haven’t gone through it, you’re not going to understand. You got a perspective; you can read it but going through is different. (participant, peer mentor, and facilitator, army)

This opinion did not discredit the knowledge provided by civilians, as a woman explained: “I have nothing against them … don’t get me wrong, but I would hate to be linked up with someone that’s not a Veteran. They don’t know our story, don’t know what we have been through” (participant, army).

Theme 2: Peer support between women Veterans provides understanding and trust, creating a non-hierarchical environment of genuine caring, non-judgement, and fun

The women’s shared experiences resulted in understanding and empathy for each other. One Veteran explained, “At the end of the day, we all understand each other. We are empathetic to one another” (participant, Marine Corps). Having this understanding further meant they were not alone, could talk and listen to each other, and had someone who cared enough to help them. Talking about why people came to the program, a Veteran said, “They see that you’re genuine and that you really do care about them and you wanna help them and then that kind of brings them in” (peer mentor, Army National Guard). Help or assistance through peer support was described in many ways. Resource-oriented assistance included system navigation, financial management, housing procurement, or trusted referral. Emotional support consisted of listening, problem solving, offering elicited advice, encouragement, advocacy, or meeting social needs. For many women, just knowing they could talk to another Veteran was viewed as helpful for well-being.

Peer support filled a social need for women to be around other Veterans. The environment created between women was perceived as an important aspect of the peer support relationship. Women described peer support as happening in a place where they felt safe, were not judged, could talk freely, and could be themselves. Peers were characterized as “somebody that they can trust, somebody that won’t judge them, somebody that is truly a friend that’s just there to care about them and help them work through whatever” (peer mentor, Army National Guard). Women gave examples of times when they simply had fun with their peers, relaxing and enjoying each other’s company. One Veteran talked about peer activities: “I think that’s the best part, we’re making something fun and exciting” (family advocate, Army Reserves, Army National Guard). At other times, and perhaps because of the established peer relationship, women felt they could talk about anything, even sensitive topics, creating an effective emotional support system. This support was denoted by a Veteran who said, “It’s that we have an understanding of where each person is. We have that, and that support system too. The camaraderie is a support system” (outreach coordinator, navy).

The women described and valued a lack of hierarchy between peers. Rank was not a factor in peer support, as one woman stated: “You can have an E1, an E6, I don’t know, if you were a captain, if you were a general, you’re up here; you’re a Veteran in need” (participant, peer facilitator, navy). Another Veteran concurred; “We’re all the same and that’s it. We’re not talking about ranks; we’re not talking about anything. We’re talking about who we are and what we are to each other, and that’s it” (program coordinator, Marine Corps). Peer support was also described as nondirective: “A peer is … not a superior looking down on you saying, ‘You have to do this’” (peer mentor, army). This equality was explained by another Veteran: “I mean, when we talk with each other, it is not at each other, and it is not on a superficial level” (peer mentor, army, Army National Guard).

Theme 3: Women Veterans consider men Veterans their peers but are more likely to disclose sensitive topics, such as sexism and assault, to other women

All but one woman indicated that biological sex was not a critical distinction in peer support. Discussing the value of men Veterans in groups, one Veteran said, “It’s fabulous in the group because in the group we’re actually just, we’re soldiers. We don’t start thinking about ‘the male, the female’ concept or treating each other differently. We’re just all soldiers” (peer facilitator, army). Most of the women saw men Veterans as their peers. One woman talked about learning from each other in group settings:

The guys may not understand the way a woman Veteran thinks and then we can always educate them, and vice versa … It’s a good support because then we get a better understanding of why the differences are between the men and women, their point of views … We’re able to talk about it. That’s a support, with better understanding. (outreach coordinator, Navy)

The exception to mixed groups occurred when women disclosed sexism or military sexual assault, indicating that they were more likely to report these experiences to other women Veterans.

Theme 4: Women Veterans view peer support as less stigmatizing, distinct from clinical therapy, and more than a job

An understanding of women Veteran peer support became even clearer when the women detailed what peer support was not. Many women regarded peer support as non-clinical, although the meaning of non-clinical was not explicitly detailed. A mentor noted, “We are always stressing it’s nothing clinical” (peer mentor, Army National Guard), and another stressed that “there has to be a handoff because we’re not clinical” (group facilitator, Air National Guard). As part of many of the programs, staff were advised to refer Veterans to outside resources when necessary. The peer role was further explained as distinct from that of a counselor, as one woman described: “What I’m not here to do is be a therapist” and “I’m not gonna label anybody as having PTSD. That’s not my job” (peer mentor, army).

Moreover, peer support among Veterans was viewed as less stigmatizing than counseling or therapy. A Veteran said, “It doesn’t hold that stigma of, well, I don’t wanna go talk to a therapist in the army because I might get in trouble or whatever” (peer mentor, army). The perceived stigma associated with therapy was acutely experienced by Veterans, even long after military service, as one explained: “When hearing the term counseling the stigma of mental health pops in our head … people will think we are incapable of being productive in society” (peer mentor, army, Army National Guard). Peer support served to normalize feelings for many Veterans: “So, it’s normal to feel that way [overwhelmed, crazy] and that’s what the peer-to-peer can do ‘cause you can say like, hey, you’re not crazy, like I felt that way too” (peer mentor, army).

Working in a peer support setting was viewed not merely as a job, but also as more personal to the women. One Veteran stated, “As a peer facilitator, I can’t just close the door of the group at the end of the day and say, okay, see you” (group facilitator, Air National Guard). The women viewed peer support unlike customer or client interactions: “You go to see maybe a clinical specialist or whatever and you don’t really have that personable … it’s very just like customer … you know, I mean, customer-based kind of thing” (peer mentor, army). One participant contrasted peer support with other groups: “I’ve gone through groups with my husband, and it’s all sad and depressing, and we’re talking about these stories and this and that, and you don’t want to be there because you’re not having fun” (family advocate, Army Reserves, Army National Guard). Peer groups were considered fun for the woman who expressed, “We want to be with each other and learn from each other and have fun” (program coordinator, Marine Corps).

Discussion

Study findings show that women Veterans conceptualized peer support as a relationship that develops between Veterans on the basis of shared experiences in the military and shared life challenges. Peer support entailed friendship, conversation, problem solving, system navigation, resource provision, and advocacy. The descriptions of women Veteran peer support in this article overlap with the existing literature on peer support, yet also differ. The shared experience of military service and unique challenges as Veterans are what distinguish this peer support from Solomon and Draine’s definition,¹¹ which is specific to having a mental health diagnosis. Rather than bonding through mental health struggles, women Veterans in this study related to each other on the basis of a shared experience of serving in the military and facing similar life challenges. Notably, the women viewed some challenges as not needing clinical intervention. Differing from Davidson et al.’s definition,¹³ the women Veterans did not limit the use of peer support to helping with serious mental illness or require that a peer be further along in the recovery process. The women Veterans spoke of peers as equals; peer relationships were not contingent on mental health status or degree of recovery.

The women Veterans’ definition of peer support among women Veterans more closely resembled Dennis’s definition of peer support in several ways.¹² Both definitions include numerous means of peer assistance, including friendship, conversation, problem solving, system navigation, resource provision, and advocacy. The assistance described by the women in this study was like Dennis’s “emotional, appraisal, and informational assistance.”^{12 (p. 329)} Both definitions require “experiential knowledge” and “similar characteristics.”^{(p. 329)} For women Veterans, the experiential knowledge was military service, and the similar characteristic was serving as women. Interestingly, some women engaged in peer support with men Veterans, indicating that men can be viewed as peers. Unlike Dennis’s definition,¹² which focuses on peer support for health-related issues, women in this study also used peer support as a sounding board or to witness another Veteran’s story.

Women Veterans’ definition of peer support in this study parallels Mead et al.’s definition in that it shares the principles of “respect, shared responsibility, and mutual agreement.”^{14 (p. 6)} For women Veterans, these principles were labeled as camaraderie, empathy, understanding, and non-judgment. Women Veterans described respect, trust, problem-solving, and understanding as crucial to peer support. Just as peer support is not a psychiatric model,¹⁴ the women Veterans emphasized that peer support was not clinical. Veteran peers do not diagnose or provide therapy; rather, they provide interpersonal support and community.

The women Veterans’ definition of peer support was most comparable to Murphy and Higgins’s definition,⁹ in that it occurs between people with some shared life experiences who provide each other with empathy, understanding, support, and a sense of shared community and belonging, unlike that given by a professional without a similar experience. Aspects shared by this definition and the women Veterans’ definition include 1) relationship, 2) shared experience, 3) assistance, 4) mutual benefit, 5) listening, 6) empathy, 7) community, and 8) non-clinical approach.

Overall, women Veterans in this study seemed to view peer support as a mutually beneficial relationship based on shared military service wherein Veterans assist one another in multiple ways beyond addressing mental health challenges. Rather than conceptualizing peer support as unidirectional, they described it as reciprocal and non-hierarchical. Unlike some definitions of peer support that may delineate a mentor-mentee relationship, women Veterans viewed peers as equals, independent of rank or branch of service. For women Veterans, peer support relationships involved listening, understanding, and empathy.

Certain aspects of Veteran peer support described by the women were new. Women Veterans conceived peer support as fun and meeting their social need to be around other Veterans. Their view of peer support did not necessarily focus on problems and, as a result, was seen as less stigmatizing than therapy. This aspect of peer support is especially poignant for Veterans, because military indoctrination may directly or indirectly discourage Veterans from addressing mental health and engaging in help-seeking behavior because of stigma.¹⁹ Participants saw peer support as a way to seek assistance that was non-stigmatizing and helped to solve problems that could be addressed with social support.

Unique to this research, the participants did not require peers to be another woman, in some cases emphasizing shared military experience over gender in peer relationships. Some women Veterans were amicable to men Veterans in group settings and even sought their perspective. However, women Veterans expressed wanting to talk with other women when discussing sexual assault, harassment, or trauma. Therefore, gender preferences should not be assumed, because women Veterans may view men Veterans as their peers. With respect to preference for groups versus individually paired peer support, participants found both options acceptable for most women, with only one woman stating she preferred to be paired with another woman Veteran. This suggests that both options should be offered to women Veterans seeking peer support services.

The ways in which women Veterans discussed peer support in this study substantiate the unique aspects of how they experience peer support. Military or Veteran culture appeared to affect how women Veterans defined peer support, further emphasizing the impact of cultural differences in its conceptualization. In these programs, Veterans stressed the importance of bonding and understanding via shared military experience, demonstrating the valuable role peer support plays in their lives. However, these programs were created by Veterans for Veterans, one of Penney’s two categories,¹⁰ so it may be that adding women Veteran peers to pre-existing programs — Penney’s other characterization — would differently shape how they viewed peer support.

Limitations

Several study limitations should also be considered. First, the use of a descriptive methodological approach using secondary data allowed participants to share rich information and reflect on their lived experience in the program settings but did not allow for further explication of or theorization about peer support between Veterans. Second, the multi-site study design added a challenge related to generalizability and application of findings beyond the sample. Although each program shared core features in terms of peer support, many other structural and operational characteristics differed between programs. These differences can be viewed as both a limitation (reduced generalizability) and a strength (increased between-cases diversity). Finally, there is a potential sampling bias in that the Veterans interviewed volunteered for these programs, leading to a sample predisposed to value and appreciate peer support.

Conclusion

This research adds to a broader understanding of peer support and helps establish the distinct value and importance of peer support among women Veterans. Peer support is an underused resource for women Veterans that has the potential to positively affect health and well-being, specifically assisting with mental health challenges and building community. Programs demonstrated the successful incorporation of military and Veteran culture into peer services, yet more can be done to include women Veterans who may feel excluded from male-dominated programs. This study informs the development of Veteran programs by adding the voices of women Veterans and illustrating the benefits of women Veterans connecting through shared military experience.

Biographies

Amanda L. Matteson, PhD, MSW, served in the Army National Guard from 2005 to 2011 as a Blackhawk helicopter mechanic and deployed in support of Operation Iraqi Freedom in 2008. She earned her bachelor’s in psychology in 2011, her master’s in social work in 2018, and her Doctor of Philosophy in social work in 2022. Her dissertation research focused on women Veteran peer support. She currently works at the Veterans Affairs War Related Illness and Injury Study Center.

Eric R. Hardiman, PhD, is an associate professor at the University at Albany’s School of Social Welfare. His research focuses on services for Veterans, mental health interventions, peer support and mutual aid, consumer-provided services, disaster relief, and psychiatric recovery. Hardiman is Principal Investigator on the New York State evaluation of the Joseph P. Dwyer Veterans Peer-to-Peer Program, as well as the New York State Office of Mental Health’s Social Work Consortium Project on Evidence-Based Mental Health Practices.

Funding Statement

This study received funding from the New York State Office of Mental Health. The points of view in this article are those of the authors and do not necessarily represent the official position or policies of the New York State Office of Mental Health. This research was also supported by the Fahs-Beck Fund for Research and Experimentation.