Treating PTSD in active duty service members using cognitive processing therapy or prolonged exposure therapy: Examining everyday practice at a military outpatient clinic

The Institute of Medicine has stressed the need for evaluations of evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) among active duty service members (AD) using a variety of evaluation approaches (Institute of Medicine, 2012). The current study examined the clinical files of 134 service members who completed treatment for PTSD using either prolonged exposure (PE) or cognitive processing therapy at an outpatient clinic. At the completion of each session, therapists made a clinical rating as to whether or not the session was protocol adherent. The total number of treatment sessions and the proportion of sessions rated as being protocol adherent were calculated. Multi-level models estimated the change in patient PTSD and other psychological symptoms over time as a function of clinician-rated protocol adherence and total number of sessions. Approximately 65% of clinic encounters were rated by therapists as being protocol adherent. Significant reductions in PTSD and psychological symptoms were associated with protocol adherence, and this was particularly true for patients who began treatment above clinical thresholds for both PTSD and other psychological symptoms. However, as the number of sessions increased, the impact of protocol adherence was attenuated. Patient characteristics, including gender, ethnicity, and co-morbidity for other psychiatric disorders were not related to symptom change trajectories over time. These findings suggest that protocol adherence and efficiency in delivery of EBTs for the treatment of PTSD with AD is critical.     

Is Established Knowledge About Cross-Cultural Differences in Individualism–Collectivism Not Applicable to the Military? A Multi-Method Study of Cross-Cultural Differences in Behavior

Preparing for international military collaboration includes raising knowledge about cultural differences. The differences in individualism–collectivism between countries are among the most central aspects likely to impact collaboration. However, are the differences in individualism–collectivism between countries as documented in a significant amount of civilian research (e.g., Hofstede, 2001a Hofstede, G. (2001a). Culture’s consequences: Comparing values, behaviors, institutions, and organizations across nations (2nd ed.). Thousand Oaks, CA: Sage. [Google Scholar]) generalizable to a military context? Or are the differences not the same in a military context, as suggested by Soeters (1997) Soeters, J. L. (1997). Value orientations in military academies: A thirteen country study. Armed Forces and Society, 24, 7–32. 10.1177/0095327X9702400101[Crossref], [Web of Science ®] , [Google Scholar] on the bases of a values survey? Quasi-experiments were conducted in a distributed collaborative computer game environment. The study is multimethod, employing self-reporting, observer ratings and direct behavioral measures, and it is the first study of cross-cultural differences in individualism–collectivism in behavior in a military context. By studying differences in collectivist-type behaviors in a sample of military officers (N = 154) in 4 different countries (the United States, the Netherlands, Sweden, and Norway), this study seeks to determine whether the cross-cultural differences in values found by Soeters from a military context are reflected in behavior. The study also includes a values survey using Hofstede’s (2007) Hofstede, G. (2007). Values survey module 1994 (VSM-94). Retrieved from www.geerthofstede.com [Google Scholar] measurement tool, the Values Survey Module (VSM), consistent with Soeters’ study. The study is considered exploratory because of a somewhat limited sample. The results from the 6 different measures of collectivist behaviors provide no support for the suggestion that cross-cultural differences in individualism–collectivism are not the same in military organizations as in civilian organizations. Although not conclusive, the results raise doubt concerning the appropriateness of using the VSM in military samples. The implications are discussed.     

Rates of Subthreshold PTSD Among U.S. Military Veterans and Service Members: A Literature Review

The current study’s goal was to provide a comprehensive review of current subthreshold posttraumatic stress disorder (PTSD) rates among U.S. military veterans and service members. PubMed, PsycInfo, ProQuest, Web of Knowledge, Google Scholar, and any relevant articles’ reference lists identified studies of subthreshold PTSD in the U.S. military. Search terms included PTSD in combination with partial, subthreshold or sub-threshold, subsyndromal or sub-syndromal, subclinical or sub-clinical, and military or veteran. Sixteen articles met criteria for review. Current subthreshold PTSD rates ranged from 2.3% to 22.3%, with a weighted mean rate of 7.6%. Definitional variation within and across the “below threshold” terms produced some variability in rates reported. Few studies consistently reported on impairment and comorbidity in the subthreshold PTSD population. Variability of current subthreshold PTSD rates may be due to methodological issues such as sampling methods, sample sizes, and how below threshold PTSD was assessed and defined. Based on our findings, we provide a number of recommendations that can be used to inform future research of subthreshold PTSD among U.S. military veterans and service members. These recommendations include having a standardized term and definition, determining how to more properly assess subthreshold PTSD symptomatology, clarifying subthreshold PTSD diagnostic stability, and identifying appropriate sampling methods.     

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.     

Effects of Hardiness and Years of Military Service on Posttraumatic Stress Symptoms in U.S. Army Medics

We examined the effects of hardiness on symptoms of posttraumatic stress (PTS) in postdeployed U.S. Army medics (N = 322). Medics endure a high level of work-related stress on and off the battlefield. Hardiness correlated negatively with reports of PTS symptoms and moderated the cumulative effects of years of military service on PTS symptoms. After controlling for socially desirable responding, PTS symptoms increased with years of military service for those with low levels of hardiness and decreased with years of military service for those with very high levels of hardiness. The military’s current resiliency training programs would likely benefit from incorporating hardiness measures and principles into its curriculum.     

Small Unit Leader Perceptions of Managing Soldier Behavioral Health and Associated Factors

This investigation explored squad leaders’ perceptions of their roles managing subordinate soldiers’ behavioral health (BH) needs. The data were obtained through an anonymous survey of 458 squad leaders (i.e., small unit leaders who oversee 4–10 soldiers). More than 80% of squad leaders perceived management of soldier BH needs before, during, and after treatment as their responsibility, and felt comfortable and capable of executing these roles. Latent class analysis was used to determine groups of “most active,” “moderately active,” and “least active” leaders. Multinomial logistic regression was used to compare the least and most active classes. The most active leaders were more likely to report high BH knowledge, dedication to a common purpose, and low levels of “associative” stigma. These results should inform leader management of soldier BH. Future research should examine active leader characteristics and whether evidence-based training can increase support for preventing and managing BH issues.     

Preliminary Evidence of Differences Between Stigma Source Versus Type With Individual Functioning Variables in National Guard/Reserve Troops

Extant military studies show that stigma has a variable association with seeking mental health treatment and mental health distress. Previous studies used a general measure of stigma that does not differentiate between stigma source or type. Stigma source can be either self-perceived or perceived from others, and stigma type can include stigma for disorder or stigma for help-seeking. Civilian literature demonstrates that self-stigma is more detrimental to individual functioning than stigma perceived from others, and prior studies in National Guard service members (NGSMs) show that self-stigma and stigma perceived from unit leaders were associated with lower help-seeking intentions relative to stigma perceived from unit members or family members. No military study has simultaneously explored the associations of demographic and distress variables with various stigma types and sources. To determine if prior mixed findings were due to the use of a general measure of stigma, NGSMs (n = 163) completed demographic and distress measures, as well as stigma source (e.g., self, leader) and type (i.e., general, disorder, help-seeking) assessments. General stigma was positively associated with all stigma types and sources as well as a college education. Disorder stigma was positively associated with stigma from nonmilitary sources, and self-stigma for help-seeking was negatively associated with help-seeking intentions. Likelihood of deploying again was positively associated with disorder and help-seeking stigma when perceived from someone in authority. Given the unique associations observed, future studies should utilize specific measures of stigma when examining factors related to postdeployment functioning.     

Initial Validation of the U.S. Army Global Assessment Tool

The U.S. Army developed the Global Assessment Tool (GAT) to monitor psychosocial fitness and well-being among soldiers and provide a means to objectively gauge the success of newly implemented resilience training programs. Despite its widespread use (taken over 5.2 million times) and stated utility for program evaluation, there is relatively little published evidence regarding the GAT’s reliability and validity. We used exploratory structural equation modeling (ESEM) with 4 random samples of soldiers (n = 10,000 each) to examine the factorial validity and reliability of the GAT. An 11-factor solution (Self-Management, Positive Affect, Meaning, Work Engagement, Organizational Trust, Loneliness, Negative Cognitions, Hostility, Negative Emotions, Depressive Symptoms, and Emotion-Focused Coping), with 4 additional factors assessing character strengths (Intellect, Warmth, Civic Strengths, and Temperance), fit well and replicated in a second random sample. A higher order, 2-factor model using composites scores and positing positive and negative psychosocial competencies also fit well. Tests of measurement invariance using a third random sample reinforced consistent measurement properties across gender, age, and rank, with the exception of character strengths, which produced different factor structures for males and females. Further validity tests using a fourth random sample underscored a modicum of divergence among the resilience factors and convergence among the character strengths factors. We conclude with recommendations for enhancing and refining the GAT and discuss the GAT’s utility as a reliable, multidimensional psychosocial assessment that can be used to evaluate the efficacy of military resilience training programs.     

Psychosocial Effects of Conditions of Military Deployment

Deployment may lead the soldiers to dichotomise their profession and their family life, resulting in unwanted effects on family or career. Effects on reintegration and functioning within family are considered. Reunions may be characterized by perceived negative reception and consequences could spill over to children as parents attempt to equivocate their differences. Risks exist for fragmentation of the family system or divorce. Social support may serve to buffer families with members on deployment.