Predictors of posttraumatic stress symptom severity and meaning made in treatment-seeking veterans.

OBJECTIVE: Combat-exposed veterans risk encountering events that disrupt beliefs. To facilitate reduced discrepancy between prior beliefs and current trauma appraisals, veterans may engage in a process of meaning-making. Meaning-making can lead to positive outcomes, such as integrating the traumatic event into one's life narrative or adapting global meaning (meaning made) or elicit distress. Given these potentially different outcomes, this study examined potential correlates of posttraumatic stress symptom (PTSS) severity and meaning made, including relationship attachment dimensions of anxiety and avoidance, and difficulties with emotion regulation, while controlling for combat exposure. METHOD: Veterans receiving mental health services at a Veterans Affairs (VA) Medical Center and a VA community-based outpatient clinic (N = 130) completed measures through a paper-and-pencil survey. Almost all participants (92%) were male, with a mean age of 55.92 years. RESULTS: In terms of meaning made, lower levels of attachment anxiety and emotional clarity (an aspect of emotion regulation) predicted higher meaning made. In terms of PTSS severity, higher attachment avoidance, attachment anxiety, and difficulties engaging in goal-directed behavior (an aspect of emotion regulation) significantly predicted higher PTSS severity. CONCLUSION: Aspects of both attachment style and emotion regulation difficulties affect meaning made and PTSS severity. These constructs may be especially relevant for clinicians working with veterans to help PTSS and support meaning made postcombat.

Understanding help-seeking in rural counties: A serial mediation analysis.

OBJECTIVE: Rural areas in the Southern United States are characterized by certain cultural values that may delay or prevent mental health service utilization. The present study examined a four-stage chain of serial mediation where higher levels of general self-reliance would be related to greater levels of public stigma, which would in turn be related to higher levels of self-stigma, followed by greater self-reliance about managing mental health problems, and finally, more negative attitudes toward seeking help from psychologists. METHOD: Community members who lived in rural counties in the Southern United States (N = 783) completed measures of these constructs online. RESULTS: Mediation analyses supported a direct association between general self-reliance and attitudes toward help-seeking that was explained in serial by higher levels of public stigma, self-stigma, and mental health self-reliance. CONCLUSIONS: Clinical implications for rural practitioners are suggested including instilling policy changes, increasing provider visibility, and addressing barriers in therapy.

Relationships among non-interpersonal and interpersonal trauma types, posttraumatic stress, and posttraumatic growth.

METHODS: Adults seeking behavioral health or medical treatment (N = 158) were recruited from a community healthcare agency and a residential support program in the southeastern United States. RESULTS: Individuals who reported interpersonal trauma had significantly higher total PTS severity and symptom clusters. No significant difference was found in perceived PTG based on trauma type. No significant curvilinear relationship between PTS and perceived PTG was found. A significant negative linear relationship was observed between PTS and perceived PTG for non-interpersonal trauma, but not interpersonal trauma. CONCLUSION: Trauma type may influence the PTS and perceived PTG relationship and, while associated with PTS, seems less important to reporting of perceived PTG.

Exploring the potential moderating role of self-compassion on the relationships between event centrality and post-assault psychological outcomes.

OBJECTIVE: The present study examined whether post-assault internal processes (i.e., present control, event centrality, and compassionate and uncompassionate self-responding) were associated with distress and resilience among women who have experienced adult sexual assault. The authors also tested whether compassionate and uncompassionate self-responses would moderate the relationships between event centrality and outcomes. METHOD: A convenience sample of women who had experienced sexual assault during adulthood (N = 253) completed an anonymous online survey. RESULTS: Regression analyses showed that lower present control, higher event centrality, and higher uncompassionate responses to the self were associated with posttraumatic stress disorder. Additionally, higher present control and higher compassionate responses to the self were associated with resilience. Moderation analyses were not significant. CONCLUSIONS: Endorsing greater levels of uncompassionate responses was associated with greater distress while engaging in greater compassionate responses was associated with greater resilience, even when accounting for levels of present control and event centrality.

Traditional rural values and posttraumatic stress among rural and urban undergraduates.

Although rurality is often treated as an aspect of diversity, researchers disagree regarding whether the traditional rural values of self-reliance, distrust of outsiders, religiosity, centrality of family, and fatalism continue to differentiate rural versus urban undergraduates. The present study examined 1) whether differences in these values exist between rural and urban college students in the United States and 2) whether these rural values might mediate the association between geographic remoteness and posttraumatic stress symptom (PTSS) severity. College undergraduates in the United States who reported experiencing traumatic and/or stressful events (N = 213) completed measures of these constructs through an online survey. T-test results indicated that rural respondents had significantly higher levels of PTSS severity and distrust of outsiders and significantly lower levels of religiosity when compared with urban participants. After controlling for gender, distrust of outsiders and religiosity also emerged as significant mediators of the relationship between geographic remoteness and PTSS severity. Thus, despite research that highlights differences based on geographic location, similarities and differences exist for rural and urban undergraduates in the United States with regard to traditionally rural values. For rural undergraduate clients presenting with trauma symptoms, our results suggest that building trust and religious and/or spiritual self-care may be particularly critical.

A qualitative analysis of meaning-making and mental health among OIF/OEF veterans.

OBJECTIVE: After combat, veterans may experience mental health symptomology and attempt to make meaning from their experiences. The present study qualitatively examined the mental health effects of deployment and meaning-making among Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) veterans. METHOD: OIF/OEF veterans who were exposed to combat (N = 14) participated in semi-structured interviews to assess how their perspectives had changed post-deployment. Most participants (86%) were male, with a mean age of 30. RESULTS: Veterans described issues post-combat that caused psychological distress or promoted distancing from others. Veterans also discussed factors that could promote or hinder meaning-making, including perceptions of growth, changed global beliefs, and disillusionment. Finally, veterans described psychological reactions to death, which could be related to moral injury. CONCLUSION: Mental health concerns, meaning-making, and consideration of mortality appear to characterize veterans' experiences post-deployment. These constructs may be important for clinicians to consider when working with OIF/OEF veterans.

Exploring the mediating role of self-blame and coping in the relationships between self-compassion and distress in females following the sexual assault.

OBJECTIVE: The present study investigated the associations between self-compassion, self-blame, disengagement coping, and posttraumatic stress disorder (PTSD) and depression symptom severity among females who had experienced sexual assault. We also examined whether the relationships between self-compassion and both PTSD and depression severity were mediated by self-blame and coping. METHOD: A volunteer sample of female adults (N = 207) completed surveys online or on paper. RESULTS: Mediational analyses showed that higher self-compassion was associated with lower behavioral self-blame, characterological self-blame (CSB), and disengagement coping which, in turn, were associated with less PTSD. Higher self-compassion was associated with less depression severity directly and indirectly via CSB. CONCLUSIONS: These findings suggest that self-compassion may be relevant for understanding postassault mental health, partially through its associations with self-blame and coping. Clinicians working with sexual assault survivors may choose to augment treatment-as-usual with interventions designed to increase self-compassion.

A pilot horticultural therapy program serving veterans with mental health issues: Feasibility and outcomes.

BACKGROUND AND PURPOSE: Veterans face challenges when returning from deployment. Many have mental health difficulties because of their service and may have significant effects on veterans' lives. Horticultural therapy has been shown to be an effective treatment for these mental health conditions. MATERIALS AND METHODS: The current study was a 5-week pilot conducted in the United States to assess a horticultural therapy program for veterans with mental health issues. RESULTS: Eight veterans completed the full 5-week pilot program. Participants reported significantly lower depression [M = 6.25 (SD = 5.23); t = 3.38, p = .01] and stress [M = 5.00 (SD = 2.56); t = 5.52, p = .001] on the Depression, Anxiety, Stress Scales. CONCLUSION: Participants provided positive feedback about the program and indicated that it was beneficial for them. Future research should be conducted with a larger sample size and control group to further validate these results.

Increased Mindfulness Skills as Predictors of Reduced Trauma-Related Guilt in Treatment-Seeking Veterans.

The present study examined the predictive role of increased self-reported mindfulness skills on reduced trauma-related guilt in a sample of veterans over the course of residential treatment for posttraumatic stress disorder (PTSD; N = 128). The residential treatment consisted of seven weeks of intensive cognitive processing therapy (CPT) for PTSD, as well as additional psychoeducational groups, including seven sessions on mindfulness skills. Increased mindfulness skills describing, acting with awareness, and accepting without judgment were significantly associated with reductions in trauma-related guilt over the course of treatment. Increases in the ability to act with awareness and accept without judgment were significantly associated with reductions in global guilt, R2 = .26, guilt distress, R2 = .23, guilt cognitions, R2 = .23, and lack of justification, R2 = .11. An increase in the ability to accept without judgment was the only self-reported mindfulness skill that was associated with reductions in hindsight bias, ß = -.34 and wrongdoing, ß = -.44. Increases in self-reported mindfulness skills explained 15.1 to 24.1% of the variance in reductions in trauma-related guilt, suggesting that mindfulness skills may play a key role in reducing the experience of trauma-related guilt during psychotherapy. Our results provide preliminary support for the use of mindfulness groups as an adjunct to traditional evidence-based treatments aimed at reducing trauma-related guilt, though this claim needs to be tested further using experimental designs.

Predictors of Posttraumatic Growth and Posttraumatic Stress Symptom Severity in Undergraduates Reporting Potentially Traumatic Events.

OBJECTIVE: Individuals often struggle to understand traumatic events. For some not yet able to successfully process the trauma, posttraumatic stress symptoms (PTS) may result, while others may report posttraumatic growth (PTG). The present study examined personality characteristics, attachment, and meaning made as predictors of PTG and PTS symptom severity. METHOD: Undergraduates reporting potentially traumatic events (N = 229) completed measures through an online survey. Over half of participants (64%) were female, with a mean age of 19 years. RESULTS: Higher extraversion, agreeableness, and conscientiousness and lower meaning made and attachment avoidance significantly predicted higher PTG. Lower neuroticism and attachment anxiety and higher meaning made significantly predicted lower PTS severity. The Meaning Made x Attachment Anxiety interaction significantly predicted PTS severity. CONCLUSION: Different facets of personality and attachment style affect PTG and PTS symptom severity. Meaning made seems especially relevant to PTS severity. These constructs may be important for clinicians working with trauma survivors to help lower distress and promote growth.

Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy.

OBJECTIVE: Although cognitive processing therapy (CPT) has strong empirical support as a treatment for posttraumatic stress disorder (PTSD), studies have not directly examined the proposed change mechanisms that underlie CPT-that change in trauma-related cognitions produces change in PTSD and depression symptoms. To improve the understanding of underlying mechanisms of psychotherapeutic change, this study investigated longitudinal association between trauma-related cognitions, PTSD, and depression among veterans receiving CPT during a 7-week residential PTSD treatment program. METHOD: All 195 veterans met DSM-IV-TR diagnosis for PTSD. The sample was 53% male with a mean age of 48 years. Self-reported race was 50% White and 45% African American. The Posttraumatic Cognitions Inventory was used to assess trauma-related cognitions. The PTSD Checklist and Beck Depression Inventory-II were used to assess PTSD and depression, respectively. Cross-lagged panel models were used to test the longitudinal associations between trauma-related cognitions, PTSD, and depression. Measures were administered at three time points: pre-, mid-, and posttreatment. RESULTS: Change in posttraumatic cognitions (self-blame; negative beliefs about the self) preceded change in PTSD. In addition, (a) change in negative beliefs about the self preceded change in depression, (b) change in depression preceded change in self-blame cognitions, and (c) change in depression preceded change in PTSD. CONCLUSION: Findings support the hypothesized underlying mechanisms of CPT in showing that change in trauma-related cognitions precedes change in PTSD symptoms. Results suggest that reduction of depression may be important in influencing reduction of PTSD among veterans in residential PTSD treatment.

Effects of self-compassion workbook training on trauma-related guilt in a sample of homeless veterans: a pilot study.

OBJECTIVE: The present pilot study examined the effects of a 4-week-long self-administered self-compassion training on trauma-related guilt and compared it to a stress inoculation control group. METHOD: A total of 47 homeless male veterans who were living in transitional housing facilities volunteered to participate in this study. Participants were randomly assigned to either a self-compassion (N = 13) or a stress inoculation (N = 14) group and were asked to complete pre-, mid-, and postintervention assessments measuring changes in self-compassion, trauma-related guilt, and posttraumatic stress disorder severity. RESULTS: Participants in both interventions reported increased levels of self-compassion and equal reductions in trauma-related guilt. No other significant changes were noted. CONCLUSIONS: The results from this pilot study provide preliminary evidence for the use of self-compassion and stress inoculation trainings as effective interventions for trauma-related guilt. The findings also suggest that self-administered trainings in the form of workbooks may be a viable, cost-effective form of intervention for disadvantaged populations, such as homeless veterans in transitional housing, who may lack resources or access to professionals or paraprofessionals. The effects of both self-compassion training and stress inoculation training on the study variables and directions for future research on self-compassion and trauma-related guilt are discussed.

The effect of self efficacy and meaning in life on posttraumatic stress disorder and depression severity among veterans.

OBJECTIVE: The current study examined the relationships among combat exposure, presence of and search for meaning in life, general and social self-efficacy, and both posttraumatic stress disorder (PTSD) and depression symptom severity for a Veteran sample (N = 93). METHOD: Participants completed an online survey comprising the Combat Exposure Scale, Meaning in Life Questionnaire, Self-Efficacy Scale, Depression subscale of the Depression, Anxiety, Stress Scales-21, and PTSD Checklist-Specific Stressor version. The majority of participants were male and Caucasian. Participants served in various service eras RESULTS: To determine factors that predicted PTSD and depression severity, separate hierarchical linear regressions were performed. In the final PTSD model, rank, combat exposure, and general self-efficacy were significant predictors, with officer rank, lower combat exposure, and higher general self-efficacy associated with lower PTSD severity. The interaction between combat exposure and general self-efficacy was also significant, with self-efficacy moderating the relationship between combat exposure and PTSD severity. For depression, rank, presence of meaning in life, and general self-efficacy were significant predictors in the model, with officer rank, higher presence of meaning in life, and general self-efficacy associated with lower depression severity. CONCLUSION: A focus on strengthening self-efficacy may assist with lower levels of PTSD and depression symptomatology after combat trauma.

Violations of war: testing the meaning-making model among Vietnam veterans.

OBJECTIVE: Posttrauma adjustment theories postulate that intense stressors violate people's beliefs about the world and perceived ability to achieve valued goals. Failure to make meaning from traumatic events exacerbates negative adjustment (e.g., PTSD), whereas success facilitates positive adjustment (e.g., stress-related growth). The current study aimed to test this model of direct and indirect effects among a sample of veterans. METHOD: Vietnam veterans (N = 130) completed assessment measures in an online survey format. Participants were largely male (91%) and Caucasian (93%) with a mean age of 61 years. RESULTS: Results supported basic model tenets, linking military stress severity to violations of beliefs and goals. In the final model, only goal violations carried indirect effects of severity on PTSD symptoms. Presence of and search for meaning carried a portion of the indirect effects between goal violations and both PTSD and stress-related growth. CONCLUSION: Findings suggest that traumatic stress may disrupt people's goals and meaning-making may center on these disruptions.

Multicultural personality and posttraumatic stress in U.S. service members.

OBJECTIVE: Modern military missions place numerous demands on service members, including tactical, personal, and cultural challenges. The purpose of this study was to explore how domains of multicultural personality (cultural empathy, open-mindedness, social initiative, emotional stability, and flexibility) and combat exposure relate to posttraumatic stress disorder (PTSD) in service members. METHOD: Participants (N = 163) completed the Multicultural Personality Questionnaire, Combat Exposure Scale, and PTSD Checklist-Military as part of an online survey. The majority of participants were Caucasian (87%), mean age was 33 years, and all were deployed at least once to Iraq or Afghanistan RESULTS: Regression results indicated that higher levels of combat exposure and open-mindedness and lower levels of flexibility and emotional stability were significant predictors of higher PTSD severity. The interactions between combat exposure and flexibility and combat exposure and openness were also significant. CONCLUSION: Higher levels of flexibility and emotional stability seem particularly important in their association with lower PTSD severity for service members.

Cognitive processing therapy for veterans with posttraumatic stress disorder: a comparison between outpatient and residential treatment.

OBJECTIVE: Across the Veterans Affairs (VA) Healthcare System, outpatient and residential posttraumatic stress disorder (PTSD) treatment programs are available to veterans of all ages and both genders; however, no research to date has compared these treatment options. This study compared veterans who received outpatient (n = 514) to those who received residential treatment (n = 478) within a VA specialty clinic on demographic and pretreatment symptom variables. Further, the study examined pre- to posttreatment symptom trajectories across the treatment programs. METHOD: All 992 veterans met diagnostic criteria for PTSD and attended at least 1 session of cognitive processing therapy (CPT) in either the outpatient or residential program. Bivariate analyses were utilized to investigate differences between samples on demographic variables and severity of pretreatment symptoms. Multilevel modeling (MLM) was used to investigate the change in symptomatology between the 2 samples from pre- to posttreatment. RESULTS: Analyses indicated that the samples differed on all demographic and pretreatment symptom variables, with residential patients reporting higher scores on all assessment measures. MLM results demonstrated that symptom scores improved for all veterans across time, with outpatients consistently reporting fewer symptoms at both time points. The time by program interaction was significant for PTSD-related symptom trajectories, but not for the depression-related symptom trajectory. CONCLUSION: This is the 1st study to compare pretreatment characteristics and treatment outcome between veterans receiving outpatient and residential PTSD treatment. Findings may help clinicians select appropriate care for their patients by identifying relevant pretreatment characteristics and generally informing expectations of treatment outcome.

Differences in relationship conflict, attachment, and depression in treatment-seeking veterans with hazardous substance use, PTSD, or PTSD and hazardous substance use.

Veterans (N = 133) who were seeking treatment in either the Posttraumatic Stress Program or Substance Use Disorders Program at a Veterans Affairs Medical Center (VAMC) and, based on self-report of symptoms, met clinical norms for posttraumatic stress disorder (PTSD) or hazardous substance use (HSU) completed a survey related to relationship conflict behaviors, attachment styles, and depression severity. Participants were grouped into one of three categories on the basis of clinical norm criteria: PTSD only, HSU only, and PTSD + HSU. Participants completed the PTSD Checklist-Military, Experiences in Close Relationships Scale-Short Form, Center for Epidemiologic Studies-Depression scale, Alcohol Use Disorders Identification Test, Drug Use Disorders Identification Test, and Psychological Aggression and Physical Violence subscales of the Conflict Tactics Scale. Most participants were male and Caucasian. Significant differences were found between groups on depression, avoidant attachment, psychological aggression perpetration and victimization, and physical violence perpetration and victimization. Post hoc analyses revealed that the PTSD + HSU group had significantly higher levels of depression, avoidant attachment, and psychological aggression than the HSU only group. The PTSD + HSU group had significantly higher levels of physical violence than did the PTSD only group, but both groups had similar mean scores on all other variables. Potential treatment implications are discussed.

Attachment, personality characteristics, and posttraumatic stress disorder in U.S. veterans of Iraq and Afghanistan.

U.S. veterans of Iraq and/or Afghanistan (N = 116) completed an Internet survey with questions related to attachment style in intimate relationships, personality factors, and posttraumatic stress disorder (PTSD). Participants completed the PTSD Checklist-Military, Experiences in Close Relationships Scale-Short Form, and the International Personality Item Pool Big Five Short Form Questionnaire. Most participants were male and Caucasian. Hierarchical linear regression analysis results indicated that emotional stability (ß = -.46, p < .001) and attachment avoidance (ß = .20, p < .05) were associated with PTSD symptom severity (adjusted R(2) = .63). An interaction between conscientiousness and attachment anxiety was found (ß = -.26, p < .001; ΔR(2) = .06), with secure attachment moderating the relationship between conscientiousness and PTSD symptom severity. Results of this study indicate that emotional stability, conscientiousness, and secure relationship attachment styles (low attachment anxiety and avoidance) are important for postcombat mental health.

Disengagement coping as a mediator between trauma-related guilt and PTSD severity.

This study examined disengagement coping as a partial mediator between trauma-related guilt and severity of posttraumatic stress disorder (PTSD) in a sample of veterans (N = 175) entering residential PTSD treatment with either PTSD or subthreshold PTSD. Disengagement coping partially mediated the relationship between guilt and self-reported PTSD severity (b = .07; 95% CI = [-.003, .13]; p = .06), but did not mediate the relationship when PTSD severity was based on clinicians' ratings. These findings bolster Street, Gibson, and Holohan's (2005) contention that higher guilt-related cognitions are related to increases in the use of disengagement coping strategies, which can interfere with PTSD recovery. The findings support the importance of PTSD treatments that target reductions in guilt-related cognitions and disengagement coping strategies.

A comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive processing therapy.

The current wars in Iraq and Afghanistan are producing large numbers of veterans who have experienced a variety of combat stressors. The potential impact of combat exposure has been established, including significant rates of posttraumatic stress disorder (PTSD). Limited research has examined potential differences between veteran groups and one study to date has examined differences between eras in terms of treatment response. The present study seeks to examine cohort differences between Operation Enduring Freedom and Operation Iraqi Freedom veterans and Vietnam veterans (N = 101) before and after completing treatment for PTSD using cognitive processing therapy. Findings suggest that veterans from these eras responded differently to treatment and there are multiple variables that should be considered in future cohort studies.