Associations Between Time Since Event and Posttraumatic Growth Among Military Veterans

Despite efforts to understand the antecedents, correlates, and consequences of posttraumatic growth (PTG), the role of time since a traumatic event (time since event) vis-à-vis PTG is not well understood. Part of a larger project exploring experiences following emotionally distressing events among military veterans (N = 197) using Amazon’s Mechanical Turk (Mturk), in the current study, we sought to clarify associations between the time since event and PTG. We used cluster-analytic techniques and analyses of variance to (a) determine the number of clusters, and (b) assess differences in core constructs of PTG and participant characteristics across clusters. Results revealed 4 significantly different groups (i.e., clusters) characterized by differential associations between PTG and time since event. These groups also differed significantly in challenge to core beliefs, level of PTSD symptoms, intrusive and deliberate rumination, and age. The immediate moderate-growth group (Cluster 1) experienced moderate levels of PTG over shorter periods of time, severe PTSD symptoms, and was significantly younger. The low-growth group (Cluster 2) was characterized by minimal PTG, regardless of time, the least challenge to core beliefs, and low amounts of intrusive and deliberate rumination. The long-term small-growth group (Cluster 3) was primarily characterized by small amounts of PTG over longer periods of time. The high-growth group (Cluster 4) was characterized by high PTG, regardless of time, greater challenge to core beliefs, the highest amount of deliberate rumination, and the highest number of PTSD symptoms. Findings underscore heterogeneity within military veterans’ experiences of PTG over time.     

Improving Mental Health Treatment Utilization in Military Veterans: Examining the Effects of Perceived Need for Care and Social Support

Many veterans with mental health problems do not adequately utilize needed care. Research has focused on identifying barriers to mental health care in veterans. The current study adds to existing literature by examining whether perceived need for treatment and social support affect treatment utilization in a national longitudinal survey of Iraq and Afghanistan veterans (n = 1,090). The Health Beliefs Model (HBM) postulates that a key reason why patients fail to obtain needed care is their belief “it’s up to me to handle my own problems.” This view was endorsed by 42% in the current national sample of veterans and was found in multivariate analysis to predict less treatment seeking in the next year. Mediation analysis revealed that veterans with higher ratings of social support were less likely to believe they needed to solve mental health problems on their own, indirectly equating to higher odds of treatment use. Simultaneously, findings indicated that posttraumatic stress disorder (PTSD) had a direct effect on more mental health visits but was also associated with higher endorsement that one needed to handle one’s own problems and thus had an indirect effect of reducing mental health visits. Both social support and PTSD affected veterans’ perceptions of needing to solve one’s own problems, significantly predicted follow-up with mental health care. As a result, the findings indicate that clinicians’ should explore veterans’ belief systems about perceived treatment need as well as investigate the role of social support to improve mental health treatment utilization.     

Childhood Sexual Assault,Quality of Life,and Psychiatric Comorbidity in Veterans With Military and Civilian Sexual Trauma

Veterans with military sexual trauma (MST) are at risk for a variety of psychiatric conditions, including posttraumatic stress disorder (PTSD) and depression. Survivors of MST are also likely to experience diminished quality of life (QoL). Individuals with higher lifetime incidence of sexual trauma may also be at increased risk for poorer outcomes in QoL and psychiatric symptomatology. The differences in psychological sequelae among those who have experienced sexual trauma as children, and those whose sexual trauma exposure is limited to adulthood are relatively understudied. The majority of sexual trauma literature has focused primarily on civilian trauma, and comparatively few studies have specifically examined psychosocial sequelae (e.g., QoL) in veterans with MST. This study examined how childhood sexual abuse (CSA) affects overall QoL as well as severity of PTSD and depressive symptoms. Veterans who reported CSA had significantly greater depression symptom severity than veterans who did not. No significant differences in PTSD symptom severity or QoL were found between veterans who did and did not report CSA. Results highlight the need for further examination of the relationship between CSA and depression in veterans with MST-related PTSD who also report CSA.     

Attachment Patterns as Mediators of the Link Between Combat Exposure and Posttraumatic Symptoms: A Study Among Portuguese War Veterans

We analyzed the role of both attachment anxiety and attachment avoidance as a mediators of the effects of combat exposure on posttraumatic stress disorder (PTSD) symptoms. Participants were Portuguese veterans (N = 60) divided into 2 groups: 30 suffered from chronic PTSD (nonrecovered) and 30 had remission from PTSD (recovered). Combat exposure, attachment patterns, and PTSD symptoms were assessed through self-report measures. Mediation test was performed by conducting several hierarchical regression analyses. Results showed higher attachment anxiety among nonrecovered participants. We did not find statistically significant differences between groups for both attachment avoidance and combat exposure level scores. In mediation analysis, at first step, attachment avoidance was not a significant predictor of PTSD symptoms, and attachment avoidance did not enter in subsequent analysis. Attachment anxiety was a partial mediator of the effect of combat exposure on PTSD symptoms. Implications of the findings for both attachment theory and clinical intervention on trauma are discussed.     

Trauma in the Lives of Older Men: Findings from the Normative Aging Study

Research on the prevalence of traumatic exposure has tended to focus on younger populations, limiting our knowledge about trauma and its effects in older adults. In this study, lifetime trauma exposure was assessed in a sample of 436 male military veterans of World War II and the Korean Conflict (age 59–92). A clinician-administered screening measure, the Brief Trauma Interview, was developed to assess lifetime exposure to 10 categories of trauma using DSM-IV criteria. PTSD was assessed in interview and questionnaires. Despite a high prevalence of trauma exposure, symptom levels were relatively low. Few men met criteria for current or lifetime PTSD. Secondary analyses found that lifetime symptom severity was higher in men who met the DSM-IV A.2 criterion, in contrast with men who did not meet A.2. Findings indicate that trauma is highly prevalent among older men, although many may be asymptomatic.     

A Review of Research on Moral Injury in Combat Veterans

The moral injury construct has been proposed to describe the suffering some veterans experience when they engage in acts during combat that violate their beliefs about their own goodness or the goodness of the world. These experiences are labeled transgressive acts to identify them as potentially traumatic experiences distinct from the fear-based traumas associated with posttraumatic stress disorder. The goal of this article was to review empirical and clinical data relevant to transgressive acts and moral injury, to identify gaps in the literature, and to encourage future research and interventions. We reviewed literature on 3 broad arms of the moral injury model proposed by Litz and colleagues (2009) Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., &; Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review, 29, 695–706. 10.1016/j.cpr.2009.07.003[Crossref], [PubMed], [Web of Science ®] , [Google Scholar]: (a) the definition, prevalence, and potential correlates of transgressive acts (e.g., military training and leadership, combat exposure, and personality), (b) the relations between transgressive acts and the moral injury syndrome (e.g., self-handicapping, self-injury, demoralization), and (c) some of the proposed mechanisms of moral injury genesis (e.g., shame, guilt, social withdrawal, and self-condemnation). We conclude with recommendations for future research for veterans suffering with moral injury.     

Rumination,Resilience, and Posttraumatic Stress Disorder Symptom Severity Among Veterans of Iraq and Afghanistan

This study investigated the relationships among combat exposure, intrusive, and deliberate rumination, resilience, and posttraumatic stress disorder (PTSD) among service members who deployed to Iraq or Afghanistan (N = 191). Participants completed an online survey and hierarchical linear regression results indicated that enlisted rank, higher combat exposure, lower resilience, and higher intrusive rumination predicted higher levels of PTSD symptom severity. Resilience moderated the relationship between combat exposure and PTSD symptom severity, such that participants who had higher levels of resilience had lower levels of PTSD symptom severity at all levels of combat exposure. These findings suggest the importance of increasing resilience in combat veterans, specifically those of enlisted rank and veterans exposed to higher levels of combat. Findings also suggest that teaching veterans how to control or minimize intrusive rumination might help lower PTSD severity.     

The Effectiveness of Emotionally Focused Couples Therapy With Veterans With PTSD: A Pilot Study

The current study is a pilot project conducted at Baltimore VA Medical Center investigating the use of emotionally focused couples therapy (EFT) for couples in which one partner is a veteran who has been diagnosed with posttraumatic stress disorder (PTSD). Fifteen couples enrolled in the study and seven of these couples completed treatment (26 to 36 weekly sessions of EFT). Both partners were assessed on measures of relationship satisfaction, psychological distress, depression, and quality of life, and veterans were assessed on measures of PTSD symptoms at baseline and 2 weeks after the intervention. Paired t-tests were used to compare scores before and after EFT. In terms of results, the veterans' partners reported significant improvements in relationship and life satisfaction and in decreased depression and a decrease in psychological distress. Veterans demonstrated a significant decrease in self-reported symptoms of PTSD. These results provide preliminary evidence for the usefulness of EFT to help foster improved relationship satisfaction, and psychological well-being for veterans with PTSD and their partners who completed treatment.     

Computer-Guided Problem-Solving Treatment for Depression,PTSD, and Insomnia Symptoms in Student Veterans: A Pilot Randomized Controlled Trial

Depression is a highly prevalent psychological disorder experienced disproportionately by college student military veterans with many deleterious effects including risk for suicide. Treatment can help, but the debilitating nature of depression often makes seeking in-person treatment difficult and many are deterred by stigma, inconvenience, concerns about privacy, or a preference to manage problems themselves. The current study examines the efficacy of a computer-guided Problem-Solving Treatment (ePST^®) for reducing symptoms of depression, posttraumatic stress disorder (PTSD), and insomnia in student military veterans. Twenty-four student veterans (Mean_age = 32.7) with symptoms of depression were randomly assigned either to a treatment group receiving six weekly sessions of ePST or to a minimal contact control group (MCC). Participants completed the Patient Health Questionnaire-9 (PHQ-9) depression scale at baseline and then weekly through post-ePST or post-MCC. PTSD and insomnia questionnaires were also completed at baseline and posttreatment. A linear mixed model regression showed a statistically significant Group (ePST vs. MCC) × Time (pretreatment through posttreatment) interaction for depression, with the ePST showing substantial improvements in depressive symptoms over the 6-week period. Significant improvements were also seen in PTSD and insomnia symptoms. Results suggest that ePST can effectively treat depression, PTSD, and insomnia symptoms in student military veterans and may be a viable alternative for those who are not able to access live therapy. Future work should examine the durability of treatment effects and utility for more severe depression and suicide prevention.     

Evaluating the effectiveness of REBOOT Combat Recovery: A faith-based combat trauma resiliency program

Evidence-based intervention programs attuned to the spiritual needs of service members, Veterans, and their families are needed to help them deal with the potentially debilitating consequences of combat trauma. This study evaluated the effectiveness of a faith-based, peer-led combat trauma resiliency program called REBOOT Combat Recovery. Participants were 254 adults who reported on 8 aspects of physical, mental, and social well-being during the 3rd week and the 12th week of the program. Findings indicated improvement for pain interference, fatigue, sleep disturbance, anxiety and depressive symptoms, and social participation. Improvement was uniform except that Veterans benefited more than currently serving military personnel with respect to anxiety symptoms. These results suggest the program may be effective for coping with the aftermath of combat trauma.     

Characteristics and Effectiveness of an Intensive Military Outpatient Treatment Program for PTSD

This study describes the characteristics and global effectiveness of treatment of a military intensive outpatient treatment program for posttraumatic stress disorder (PTSD). Thirty-nine military personnel completed treatment outcome questionnaires. Results showed a statistically significant reduction in depression and PTSD symptoms after the participants completed 3 weeks of intensive outpatient therapy. The findings have clinical and research implications for the length, intensity, and focus of PTSD treatment.     

Killing Versus Witnessing Trauma: Implications for the Development of PTSD in Combat Medics

Killing in combat uniquely predicts elevated PTSD symptomatology among military veterans. This study investigated the effects of combat killing in a sample of 345 U.S. Army combat medics who had recently returned from operational deployments to Iraq or Afghanistan. Combat medics provide frontline medical care before, during, and after battles but also fight alongside other soldiers when under attack. Attempting to kill in combat was a significant predictor of PTSD symptomatology even after accounting for passively witnessing trauma in fellow soldiers. Medics may be well prepared to cope with the passive experiencing and witnessing of war-zone trauma, but may benefit from training to cope with the negative consequences of taking actions to kill.     

The Role of Political Practices in Moral Injury: A Study of Afghanistan Veterans

While much research has been conducted on military trauma, conceptualizations of deployment‐related suffering have been predominantly approached through a medical, individual‐focused lens. Since the military is an instrument of the state, it is crucial to expand the conceptual scope to include political processes, particularly for the fast‐growing literature on “moral injury,” which refers to the emotional impact of perpetrating, witnessing, or falling victim to perceived wrongdoing. This article examines the role of political practices in the onset of moral injury as well as the micropolitical responses of morally injured veterans. A study of the Dutch mission in Uruzgan, Afghanistan, shows that decisions and frames at the political level helped create distressing quandaries on the ground and that in all the ways the political leadership acknowledged the problems that veterans subsequently developed, it also maintained a silence on its direct contribution to these problems, as such perpetuating them. Consequently, veterans tried to make the political leadership take a material and symbolic share in their burden. Clearly, moral conflict may exist both in the veteran and between the veteran and the political domain, and therefore, experiences of institutional betrayal and a resultant search for reparations should be included in theory on moral injury.     

A Cross-Lagged Panel Approach to Understanding Social Support and Chronic Posttraumatic Stress Disorder Symptoms in Veterans: Assessment Modality Matters

Although there is a strong and consistent association between social support and posttraumatic stress disorder (PTSD), the directionality of this association has been debated, with some research indicating that social support protects against PTSD symptoms, whereas other research suggests that PTSD symptoms erode social support. The majority of studies in the literature have been cross-sectional, rendering directionality impossible to determine. Cross-lagged panel models overcome many previous limitations; however, findings from the few studies employing these designs have been mixed, possibly due to methodological differences including self-report versus clinician-administered assessment. The current study used a cross-lagged panel structural equation model to explore the relationship between social support and chronic PTSD symptoms over a 1-year period in a sample of 264 Iraq and Afghanistan veterans assessed several years after trauma exposure. Approximately a third of the sample met criteria for PTSD at the baseline assessment, with veterans’ trauma occurring an average of 6 years prior to baseline. Two separate models were run, with one using PTSD symptoms assessed via self-report and the other using clinician-assessed PTSD symptoms. Excellent model fit was found for both models. Results indicated that the relationship between social support and PTSD symptoms was affected by assessment modality. Whereas the self-report model indicated a bidirectional relationship between social support and PTSD symptoms over time, the clinician-assessed model indicated only that baseline PTSD symptoms predicted social support 1 year later. Results highlight that assessment modality is one factor that likely impacts disparate findings across previous studies. Theoretical and clinical implications of these findings are discussed, with suggestions for the growing body of literature utilizing these designs to dismantle this complex association.     

A Mixed‐Methods Evaluation of Intensive Trauma‐Focused Programming

This study investigated the magnitude of treatment effect and clients' perceptions of change during a 10‐week intensive outpatient program (IOP) for individuals with posttraumatic stress disorder. Participants were 48 adults (30 women, 18 men) with a mean age of 43.48 years (SD = 12.16) who were predominantly European American (72.9%, n = 35). Results of a mixed‐methods sequential explanatory design indicated that the IOP was strongly associated with decreased psychological symptom severity and increased relational health among participants over time.     

Psychotherapeutic Interventions for Symptom Reduction in Veterans With PTSD: An Observational Study in a Residential Clinical Setting

Cognitive processing therapy (CPT) and eye movement desensitization and reprocessing (EMDR) therapy were compared for veterans in a posttraumatic stress disorder (PTSD) residential program (N = 51) who received individual EMDR and group CPT, individual CPT and group CPT, or trauma group exposure (TGE) therapy. Analyses revealed an overall significant difference on posttest measures of the PTSD Checklist for individual EMDR/group CPT and individual CPT/group CPT when compared to TGE, with no significant difference found between EMDR and CPT. Depression scores were significantly decreased between pre- and posttest for patients who received individual EMDR/group CPT. Results support EMDR and CPT as clinically effective and complementary treatments in residential PTSD treatment programs.     

Psychosocial Characteristics of Student Veterans with Service-Related Disabilities: Implications for Further Research and Occupational Therapy Involvement

The purpose of this study was to assess how post-9/11 university student veterans differ from nonveteran university students on four mental health indicators. In comparison to a demographically matched sample of nonveteran students, it was found that veterans in this study had significantly higher levels of depression and post-traumatic stress symptomatology and non-significantly lower levels of engagement in meaningful activities and meaning in life. This non-experimental study indicates that mental health differences between student veterans and their nonveteran peers do exist, and argues for the inclusion of occupational therapy services for student veterans.     

Adapting Cognitive Processing Therapy for PTSD for People With Disabilities: A Case Study With a U.S. Veteran

Many veterans receiving treatment for PTSD in the VA health care system are also living with a disability and utilize assistive technologies for communication and/or mobility. While evidence-based treatments for PTSD have been disseminated in VA hospitals nationwide, clinicians may have concerns about implementing these treatments with people with disabilities or question how to adapt evidence-based protocols to facilitate successful outcomes. This clinical case study details the treatment of a 48-year-old male U.S. veteran with a diagnosis of military-related PTSD and significant functional and communicative complexities characteristic of locked-in syndrome. The study implemented an adapted protocol of Cognitive Processing Therapy (CPT), a first-line evidence-based psychotherapy for PTSD with unknown application to people with disabilities. CPT protocol structure, length, and delivery was adapted to accommodate the veteran’s assistive devices and functional abilities. The veteran experienced a clinically significant reduction in PTSD symptoms over the course of treatment, suggesting successful application of the adapted protocol. In addition to symptom reduction, the veteran reported advances in his ability to tolerate emotional distress while engaged in goal-directed behavior and improved interpersonal functioning. Results suggest that CPT can be adapted and effective in instances where the presence of disability and multiple assistive technologies impact standard treatment implementation. This information is valuable in its potential ability to make evidence-based psychotherapies more accessible and disability-sensitive. Clinical recommendations for using and adapting CPT for people with disabilities are provided.     

The structure of DSM-5 posttraumatic stress disorder symptoms in war veterans

Background and Objectives: The present research examined the underlying factor structure of posttraumatic stress disorder (PTSD) as conceptualized in the recently published fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5). Design: Participants were 258 trauma-exposed Iraq/Afghanistan war veterans. Methods: A self-report measure of PTSD symptoms was administered to all participants and confirmatory factor analysis (CFA) was used to compare several different models of PTSD. Results: CFA revealed that the best-fitting model was a six-factor model in which symptoms loaded onto the factors of intrusion, avoidance, negative affect, anhedonia, dysphoric arousal, and anxious arousal. Conclusions: These findings have important implications for ongoing conceptualization of PTSD and suggest that additional modifications to the diagnostic criteria for PTSD may still be warranted to more accurately reflect the underlying structure of PTSD symptoms.