Running head: MILITARY POST-TRAUMATIC STRESS

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Mitigating Stressors of Military Service in Prevention of Post-Traumatic Stress Disorder: Increases in Psychoeducation Prior to Deployment Zackery A. Tedder Texas State University – San Marcos

Author Note Zackery A. Tedder, Department of Psychology, Texas State University – San Marcos

MILITARY POST-TRAUMATIC STRESS Correspondence concerning this article should be addressed to Zackery A. Tedder, Department of Psychology, Texas State University – San Marcos, San Marcos, TX 78666. Contact: zt1011@txstate.edu.

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MILITARY POST-TRAUMATIC STRESS Abstract Post-Traumatic Stress Disorder (PTSD) shows significant prevalence in United States service members returning from war. Intervention strategies exist for treatment of PTSD with suitable efficacy, but few prevention strategies have shown efficacious outcomes. Strategies of interventions are used to determine a plausible new approach to try to mitigate onset of PTSD symptomology by means of enhanced psychoeducation prior to deployment. Measures of anxiety, depression, and PTSD symptomology are used to determine the effect of enhanced psychoeducation.

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MILITARY POST-TRAUMATIC STRESS Mitigating Stressors of Military Service in Prevention of Post-Traumatic Stress Disorder: Increases in Psychoeducation Prior to Deployment Post-Traumatic Stress Disorder (PTSD) is a common theme in today’s society. Many of

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us deal with horrific traumas at some point in our lives. For members of the military, this is even a more prevalent reality. With wars stretching for a decade, American service members are showing increased rates of PTSD diagnoses, which have a current estimated prevalence range between 4% and 17% (Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2011). While treatment strategies range from psychopharmacology to Cognitive-Behavioral Therapy, very few prevention strategies exist due to the fluid nature of military service and combat deployment. Strategies do exist for engaging military service members into treatment plans to obtain counseling, however, approximately 25% are actually receiving care (Strachan et al., 2011). With a current total of approximately 3 million service men and women on Active or Reserve duty (Office of the Under Secretary of Defense for Personnel and Readiness, 2011), and many of them being deployed to active war theaters, the rate of PTSD diagnose will likely continue to rise. This article will look at current approaches for intervention strategies and preventative measures in this population, and examine the effects of the treatment models. It will also assess the effectiveness of current coping strategies in this population. Post-Traumatic Stress Disorder is characterized by several criteria for diagnoses. According to the Diagnostic and Statistical Manual (American Psychiatric Association, 2000), there are six criteria that are necessary for diagnoses. Criterion A is defined as a stressor in which there was an event that involves actual or threatened death or serious injury, and the response involved intense fear, helplessness or horror. Criterion B is considered intrusive recollection in which the event is persistently re-experienced. Criterion C is avoidance or

MILITARY POST-TRAUMATIC STRESS numbing of stimuli associated with the traumatic event and a general numbing of general responsiveness which was not present before the trauma occurred, and Criterion D is identified with hyper-arousal in persistent symptoms which were not present before the trauma. The disturbance should have duration of longer than one month (Criterion E), and should have clinically significant distress in social, occupational, or other important areas of functioning (Criterion F). Previous Research Coping strategies among military veterans tends to be low due to the lack of knowledge, combined with perceptions and stigma of receiving psychological care. Research shows that most veterans choose self-medication to cope rather than seek individual therapy. One highly used substance amongst veterans in cannabis. Previous literature has shown that multiple traumatic exposures are being associated in increased rates of cannabis use among military veterans (Bonn-Miller, Vujanovic, & Drescher, 2011). However, there have been significant deficits in understanding the direct link of PTSD symptomology and cannabis use as a coping strategy. In the analysis of the members surveyed in this study, a measurement of change in the symptomology assessed at intake and discharge of a residential treatment facility was directly associated with predictability of cannabis use. The findings suggested that those who did not show a significant change in severity of symptoms after treatment had a greater likelihood of using cannabis as a coping method. Interestingly, the study points out that 10% of participants who were abstinent in use of cannabis at a 2-month pre-treatment period started using at a 4month follow-up. This is believed to be directly attributed to the perception that cannabis use has a certain efficacy in coping with PTSD symptomology.

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MILITARY POST-TRAUMATIC STRESS An emerging process in the arena of prevention strategies are formulating in the development of prevention groups. Research performed by Harpine, Nitza, and Conyne (2010)

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discuss the benefits of these prevention groups and of the increase in availability of them. These “group psychologists” are themed in the 11 therapeutic factors of group processes as defined by Yalom and Leszcz (2005): Instillation of hope, universality, imparting information, altruism, recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. (pg. 269) These factors play a significant role in group prevention, due to the interconnected nature of why groups form for prevention purposes. Another aspect is universality. By accepting the fact that we are all human and experience much of the same range of emotions is thought to help alleviate fears of isolationism, and encourage acceptance. Through their research, they found that coping skills were improved, and that protective strategies had positive outcomes in their practice with families, in workplaces, and even in adolescents. The article suggests that prevention programs should continue to grow, and further accessibility should be a goal of the psychological community. Treatment of PTSD has many different approaches. Because the Department of Veterans Affairs (VA) provides a majority of treatment modalities, there is a wealth of different approaches available. One such treatment involves a technique known as “telehealth.” Telehealth delivers care to patients through a video-conferencing method. Emerging research from Strachan et al. (2011) discusses the implementation of home-based delivery services for the treatment of PTSD. This approach entails using a Behavioral Activation and Therapeutic

MILITARY POST-TRAUMATIC STRESS Exposure (BA-TE) technique which uses systematic desensitization and exposure therapy. The idea is that these strategies will encourage activities that “may broaden the therapeutic range of exposure (Strachan, 2011).” This has high implications for treatment delivery, as previous models focused on outpatient models served within a VA hospital. In examining both physiological features and psychopathology, researchers were able to significantly reduce primary symptoms of PTSD with BA-TE treatment through telehealth, indicating that this may

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widen availability to members who might not otherwise seek treatment. However, ethical issues in delivering treatment through this model are still highly debated. Daily stressors may exacerbate PTSD symptomology due to decreased coping effectiveness. Research by Bartley and Roesch (2010) suggest that conscientiousness may be mediated by coping in maintaining positive affect. They note that individuals with high levels of conscientiousness “show high levels of self-regulation, persistence, and impulse control (2010).” Their research yielded individuals with high conscientiousness used more problem-focused coping strategies, which was associated with higher levels of positive-affect. This has interesting implications for individuals with PTSD, as improvement of regulation in regards to conscientiousness may be a suitable strategy for improving coping efficacy, thereby alleviating symptoms of PTSD. Coping strategies are typically examined in patients who have been diagnosed with PTSD for numerous reasons. Mainly, the dysfunctional nature of cognitive processes which are disrupted by the disorder can lead to excessive worry or hypersensitivity. Research by Pietrzak, Harpaz-Rotem, & Southwick (2011) explain that there exists a large amount of research regarding avoidance in the PTSD population, and that avoidance symptoms lead to increases in both severity and chronicity of PTSD. They also suggest that low amounts of social support

MILITARY POST-TRAUMATIC STRESS after a traumatic event predicts the severity of onset. What they discovered was that modifying maladaptive coping strategies proved beneficial in treating veterans, but stressed that a modification in problem-focused coping helped combat PTSD symptoms. Also, increases in

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social support, and an active coping style may help decrease severity. Most importantly, treating social avoidance was deemed to be highly beneficial in social interaction, which is typically mediated by lack of understanding by others. It should be further noted that this study only examined veterans who were treatment-seeking. Another implication of stress and coping is that of goal disturbance and its effect on coping strategies. Research by Schroevers, Kraaij, & Garnefski (2007) posits that psychological distress can materialize when individuals are incapable of maintaining their desired goals caused by a stressful event. These events are defined as loss (i.e., death of a close friend or relative), health threats (i.e., illness or injury), or relational stress experiences. Analysis showed that the type of event dictated which type of coping strategy was implemented by the individual, and how it affected depressive symptoms. These symptoms led to goal disturbance, which in turn manifested in rumination and catastrophizing, which were further identified as maladaptive coping strategies. It was found that positive reappraisal was the most adaptive coping strategy when faced with goal disturbance, basically promoting flexibility in future goal attainment. These findings provide clinical implications that helping patients become aware of maladaptive thinking and re-evaluate negative interpretations are critical improvements leading to decrease in ineffective coping abilities. Values play an interesting role in stress prevention, due to its necessity in a working existence. Because of the negative implications of stress and its physiological effects, research has been conducted in the measure of values and its role in stress prevention. Researcher

MILITARY POST-TRAUMATIC STRESS Gunvor Gard (2003) defined values as “the shared principles which guide behavior in an organization.” His research asked people their view of values and how it affected their job

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performance. In all, 80% believed that their coping strategies were directly associated with their ability is coping with stress in their daily situations, which led to the motivation and high engagement in their work lives. Gard states that patients who were motivated and valued their jobs led healthier lives and more effective coping strategies. Finally, one of the key components of PTSD is recurrence of the event. These recurrences can take form in nightmares which may affect quality of life in those suffering with PTSD. Long et al. (2011) examined the implications of nightmares with the use of imagery rescripting and exposure treatment (IRET) due to the decade’s long persistence following the original trauma. In imagery re-scripting, the distressing nightmare is changed to be less threatening through written analysis and then positively reframed, thereby increasing habituation and modifying maladaptive beliefs. Results showed that over 6 sessions, 15% no longer reported having nightmares, 30% reported having 6 or more hours of sleep, and 90% reported at least mild overall improvements. In all, 27% no longer met the criteria for PTSD diagnosis. Due to the burgeoning nature of this research, further investigation is implied. In all, there are multiple facets required to be examined in creating a prevention strategy that could possibly mitigate the effects of war-time PTSD. Deficits in prevention reflect that a more than “abstinence only” stance on cannabis use should be integrated into psychoeducation in regards to coping. Sadly, it is impossible to determine the efficacy of in-place strategies due to the limited amount of available research into what is currently practiced. Research should reflect current methodologies offered within the military to evaluate their effectiveness, however, these approaches are not available to civilians outside of the military structure.

MILITARY POST-TRAUMATIC STRESS Natural prevention groups already exist in the military due to the cohesion of service.

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Where problems start is upon separation from service, and the social support network is severely reduced. While VA facilities offer group counseling services, local external organizations should be further established in order to provide greater service availability. This could be established by the individual members themselves, and do not always require the intervention of trained counselors. By helping veterans identify more severe problems within each other may prove beneficial to ensuring that those who need help the most receive it. With only 25% of veterans taking advantage of services offered through the VA, further efforts to encourage participation should be pursued by outside means. Psychoeducation in significant coping strategies to enhance the prevention of hyperarousal sustainment, and its effects on the cardiovascular system was never discussed in these articles, except to note that it was necessary for diagnosis. This is bothersome insofar as research reflects that veterans seem to choose maladaptive coping methods by abusing substances like alcohol and marijuana to deal with the stresses of post-combat life, which also have cardiovascular implications. By educating individuals in hyper-arousal and nightmare occurrence is thought to promote healthier lifestyles, thereby mediating these physiological effects. Externalization of values outside the military can be a difficult transition. Transition assistance is already in place, however, does not go so far as to help these individuals identify how their service may be reflected in their new civilian life in regards to their new-found careers. Increases in conscientiousness and values should also be integrated into transition assistance programs currently provided to assist in returning to the civilian world.

MILITARY POST-TRAUMATIC STRESS Method Participants This prevention strategy will engage two platoons of United States Army Infantry Soldiers within the same Company as the population target in the mobilization phase of deployment. This would likely occur approximately 30 days prior to actual ship-out date.

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Platoons are typically made up of between 25 and 50 people. This would make the sample size approximately 100 people. Two conditions would be established with one receiving enhanced psychoeducation (EPE) and one with typical psychoeducation (TPE) that the military already provides prior to deployment. Participants would be a stationed at Fort Hood, TX. Eligibility would be established for all members age 18-45 within the platoon, including leadership (enlisted and officer), for those who had not been previously deployed to an active war theater and who had not received any pre-deployment training on strategies related to anxiety or trauma. Individuals with substance abuse problems would be excluded. Procedures Psychoeducation will focus on identifying risk factors, coping methodologies, cognitive processing of trauma, and identification of individual resistance as means to understanding the impact of potential stressors and traumatic events. Psychoeducation is currently in use within the military structure, however, availability to the specifics are unknown and unavailable. It will have to be assumed, then, that identification of changes in behavior and affect, depression symptomology, reaction to trauma, and recurrence of visions of the possible event or nightmares is already being taught at the command level prior to deployment.

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On top of that already existing training, strategies of coping and stress management will be implemented. Specifically, problem-focused coping will be used to ensure that service members are adequately able identify what the root cause of the stressor or trauma, and learn techniques to overcome those stressors in a dangerous and unpredictable environment. A brief video would be produced explaining the dangers of rumination, and maladaptive coping styles to convey the importance of catharsis following a traumatic event to attempt to mitigate onset. This video will show previously deployed soldiers, now separated from service, which are living with the long-term effects of PTSD and attempt to relay a loss-framed message of declining treatment or therapeutic services. Prevention groups will be established prior to deployment to ensure the ongoing acceptance of psychoeducation and continued communication building between members. Measures The PTSD Checklist – Military (PCL-M) is a 17-item measure designed to assess PTSD symptom severity (Weathers et al., 1993). The PCL has been shown to have excellent internal consistency (αs>.94) and excellent test-retest reliability in various populations (r =.96). Further, the PCL has demonstrated excellent convergent validity with alternative measures of PTSD (rs range from .77 to .93; Orsillo et al., 2001). Sensitivity and specificity of this instrument is set at a score of 50 for diagnosis by the VA. The General Coping Questionnaire (GCQ-30) is a 30-item instrument with 4 subscales, consisting of emotional expression, emotional support seeking, cognitive reinterpretation, and problem solving. It uses a 5-point Likert scale to assess the capability of the individual being assessed. It has shown good internal consistency (30 items; α = .81; Eid, Thayer, & Johnson,

MILITARY POST-TRAUMATIC STRESS 1999) and test-retest reliability (r=.66, p < .05; Eid, Thayer, & Johnson, 1999). This scale will

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be crucial in identification of maladaptive coping strategies, and the assessment of availability of social support. The Beck Anxiety Inventory (BAI) is a 21-item measure designed to assess the severity of anxiety in psychiatric populations (Beck & Steer, 1993). The BAI has demonstrated adequate test-retest reliability over a one-week interval (r = .75), excellent internal consistency (α = .92), and convergent and discriminant validity in multiple samples (Beck, Epstein, Brown, & Steer, 1998; Beck & Steer, 1993). The Beck Depression Inventory – 2nd Edition (BDI-II) is a 21-item measure designed to assess the cognitive, affective, behavioral, motivational, and somatic symptoms of depression in adults and adolescents (Beck, Steer, & Brown, 1996). The BDI-II has demonstrated excellent test-retest reliability over a 1-week interval (r=.93), excellent internal consistency (αs<.92) and convergent and discriminant validity in multiple samples (Beck et al., 1996). Results Within the two experimental groups, we will compare the existing Typical Psychoeducation (TPE) with the Enhanced Psychoeducation (EPE), which will include the video previously mentioned. The control group would receive the TPE, and the experimental group would receive the EPE. Measurements will be taken post-deployment upon return and debriefing. Screening will be accomplished with the PCL-M to measure effects of onset, if present. Measures of anxiety and depression will also be measured in both groups using the BAI and BDI, respectively. The GCQ-30 will be used to assess coping ability after deployment to distinguish possible maladaptive coping styles once back in the United States. A one-year

MILITARY POST-TRAUMATIC STRESS follow-up will be recommended for individuals who may be separated from Active Duty status to assess long-term effects of the prevention strategy. Statistical analysis will be used to measure between group effect size, and compared

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through SPSS software. Data will be analyzed using an Independent Measure T-Test to examine effect size between the two groups and evaluate the power of the intervention.

MILITARY POST-TRAUMATIC STRESS References

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. Bartley, C. E., & Roesch, S. C. (2010). Coping with daily stressors: The role of conscientiousness. Personality and Individual Differences, 50, 79-83. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1998). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897. Beck, A. T., & Steer, R. A. (1993). Manual for the Back Anxiety Inventory. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. & Brown, G. (1996). Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. Bonn-Miller, M. O., Vujanovic, A. A., & Drescher, K. D. (2011). Cannabis use among military veterans after residential treatment for posttraumatic stress disorder. Psychology of Addictive Behaviors, 25(3), 485-491. Eid, J., Thayer, J. F., & Johnsen, B. H. (1999). Measuring post-traumatic stress: A psychometric evaluation of symptom- and coping questionnaires based on a Norwegian sample. Scandanavian Journal of Psychology, 40, 101-108. Harpine, E. C., Nitza, A., Conyne, R. (2010). Prevention groups: Today and tomorrow. Group Dynamics: Theory, Research, and Practice, 14(3), 268-280.

MILITARY POST-TRAUMATIC STRESS Melançon, G., & Boyer, R. (1999). How to prevent post-traumatic stress disorder before traumatization occurs?. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 44(3), 253-258. Office of the Under Secretary of Defense for Personnel and Readiness. (2011). Armed forces strength figures for September 30, 2011 [Data file]. Retrieved from http://siadapp.dmdc.osd.mil/personnel/MILITARY/ms0.pdf Orsillo, S. M., Batten, S. V., & Hammond, C. (2001). Measures for acute stress disorder and posttraumatic stress disorder. In M. M. Antony, S. M. Orsillo, & L. Roemer (Eds.),

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Practitioner’s guide to empirically based measures of anxiety (pp. 255-307). New York: Springer. Pietrzak, R. H., Harpaz-Rotem, I., & Southwick, S. M. (2011). Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF-OIF veterans. Psychiatry Research, 189, 251-258. Schroevers, M., Kraaij, V., & Garnefski, N. (2007). Goal disturbance, cognitive coping strategies, and psychological adjustment to different types of stressful life events. Personality and Individual Differences, 43, 413-423. Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C. W., & Acierno, R. (2011). An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: Preliminary findings. Behavior Therapy, manuscript submitted for publication.

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