Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder With Active Duty U.S. Military Personnel: Special Considerations and Case Examples

Wachen, Jennifer Schuster; Dondanville, Katherine A.; Pruiksma, Kristi E.; Molino, Alma; Carson, Cody S.; Blankenship, Abby E.; Wilkinson, Charity; Yarvis, C.O.L. Jeffrey S.; Resick, Patricia A.

doi:10.1016/j.cbpra.2015.08.007

Cited by 32 publications

(18 citation statements)

References 30 publications

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“…However, in combination with assessments for prominent mental health conditions in military populations (e.g., PCL 5, PHQ‐8, and AUDIT‐C), this instrument might identify patients who are morally injured. In such cases, clinicians might incorporate alternate strategies for alleviating MI that are typically not a salient part of evidence‐based treatments for PTSD/MDD (for examples, see Farnsworth et al, ; Gray et al, ; Koenig et al, 2016; Maguen & Burkman, ; Nieuwsma et al, ; Wachen et al, ). Depending on whether patients' expressions are directed at self or others, they may benefit from emotion‐focused strategies aimed at promoting forgiveness of self or others (e.g., unfinished business or self‐evaluative split chairing interventions; Greenberg, 2015).…”

Section: Discussionmentioning

confidence: 99%

“…Although the MI construct has relevance for other trauma‐exposed groups, not contextualizing and anchoring the items for this population may limit their sensitivity to identify morally injured men and women. In addition, evidence‐based treatments for PTSD/MDD are being adapted to address traumatic themes related to MI (e.g., Gray et al, ; Koenig et al, ; Maguen & Burkman, ; Nieuwsma et al, ; Wachen et al, ). Without a tool for obtaining a comprehensive picture of MI expressions, clinicians may lack information to tailor treatment along these lines or determine whether their patients are experiencing desirable outcomes.…”

Section: Introductionmentioning

confidence: 99%

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Development and evaluation of the Expressions of Moral Injury Scale—Military Version

Currier

Farnsworth

Drescher

et al. 2017

Clin Psychology and Psychoth

146

211

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There is consensus that military personnel can encounter a far more diverse set of challenges than researchers and clinicians have historically appreciated. Moral injury (MI) represents an emerging construct to capture behavioural, social, and spiritual suffering that may transcend and overlap with mental health diagnoses (e.g., post-traumatic stress disorder and major depressive disorder). The Expressions of Moral Injury Scale-Military Version (EMIS-M) was developed to provide a reliable and valid means for assessing the warning signs of a MI in military populations. Drawing on independent samples of veterans who had served in a war-zone environment, factor analytic results revealed 2 distinct factors related to MI expressions directed at both self (9 items) and others (8 items). These subscales generated excellent internal consistency and temporal stability over a 6-month period. When compared to measures of post-traumatic stress disorder, major depressive disorder, and other theoretically relevant constructs (e.g., forgiveness, social support, moral emotions, and combat exposure), EMIS-M scores demonstrated strong convergent, divergent, and incremental validity. In addition, although structural equation modelling findings supported a possible general MI factor in Study 2, the patterns of associations for self- and other-directed expressions yielded evidence for differential validity with varying forms of forgiveness and combat exposure. As such, the EMIS-M provides a face valid, psychometrically validated tool for assessing expressions of apparent MI subtypes in research and clinical settings. Looking ahead, the EMIS-M will hopefully advance the scientific understanding of MI while supporting innovation for clinicians to tailor evidence-based treatments and/or develop novel approaches for addressing MI in their work.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Development and evaluation of the Expressions of Moral Injury Scale—Military Version

Currier

Farnsworth

Drescher

et al. 2017

Clin Psychology and Psychoth

146

211

View full text Add to dashboard Cite

show abstract

“…In addition to the aforementioned provider‐level variables, a number of factors have been proposed to explain differential findings between military‐affiliated patients and civilians like those observed in the present study. For example, researchers have noted the potential role of warrior ethos (e.g., “I will never accept defeat”) and other aspects of military training and culture that might make PTSD treatment more difficult, such as valuing approach‐focused responses like anger over more vulnerable emotions such as sadness or grief that may be important for recovery (Dillon et al., ; Wachen et al., ). We did not find any differences when types of military affiliation (i.e., veteran vs. active duty) were compared; however, these analyses may have been limited by insufficient power to detect differences between groups.…”

Section: Discussionmentioning

confidence: 99%

The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community

Dillon

LoSavio

Henry

et al. 2019

Journal of Traumatic Stress

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Military-affiliated individuals (i.e., active duty personnel and veterans) exhibit high rates of posttraumatic stress disorder (PTSD). Although existing evidence-based treatments for PTSD, such as cognitive processing therapy (CPT), have demonstrated effectiveness with military-affiliated patients, there is evidence to suggest these individuals do not benefit as much as civilians. However, few studies have directly compared the effects of PTSD treatment between civilian and military-affiliated participants. The current study compared treatment outcomes of military-affiliated and civilian patients receiving CPT. Participants with PTSD who were either civilians (n = 136) or military-affiliated (n = 63) received CPT from community-based providers in training for CPT. Results indicated that military-affiliated participants were equally likely to complete treatment, Log odds ratio (OR) = 0.14, p = .648. Although military-affiliated participants exhibited reductions in PTSD, B = −2.53, p < .001; and depression symptoms, B = −0.65, p < .001, they experienced smaller reductions in symptoms relative to civilians: B = 1.15, p = .015 for PTSD symptoms and B = 0.29, p = .029 for depression symptoms. Furthermore, variability estimates indicated there was more variability in providers' treatment of military-affiliated versus civilian participants (i.e., completion rates and symptom reduction). These findings suggest that military-affiliated patients can be successfully retained in trauma-focused treatment in the community at the same rate as civilian patients, and they significantly improve in PTSD and depression symptoms although not as much as civilians. These findings also highlight community providers' variability in treatment of military-affiliated patients, providing support for more military-cultural training.

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“…Wachen et al. () described the just‐world belief as the notion that “actions and conditions have predictable and appropriate consequences determined by moral fairness in a just world” (p. 140). This definition highlights that in the various expressions of the just‐world belief, clients use prescriptive cognitions to shape their descriptive understanding of the causal explanations for events.…”

Section: Manifestations Of Descriptive and Prescriptive Cognitions Inmentioning

confidence: 99%

“…Yet, other evidence suggests that these interventions may be relatively less effective in military populations (Steenkamp, Litz, Hoge, & Marmar, ), which has prompted some researchers to propose that military traumas involve moral concerns distinct from those that present themselves in civilian populations (Gray, Nash, & Litz, ). At the same time, other researchers have contended that these elements of moral injury are adequately addressed by traditional PTSD treatments (Smith, Duax, & Rauch, ; Wachen et al., ). If the moral injury construct is to continue to mature, further clarity on these points is needed to inform treatment and research.…”

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confidence: 99%

Is and Ought: Descriptive and Prescriptive Cognitions in Military‐Related Moral Injury

Farnsworth

2019

Journal of Traumatic Stress

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Debate exists regarding the most appropriate way to address moral injuries that stem from involvement in war and other military conflicts. In recent years, some researchers have suggested that existing treatments for trauma may be inadequate to address moral injury and have thus proposed novel interventions to help mitigate these concerns. In response, advocates of more traditional approaches have argued that standard trauma interventions are generally sufficient for moral injury, and investment in new interventions may be premature. This conceptual article draws from research findings and current theories of moral injury to demonstrate that there is merit on both sides of this debate, and further clarifying the types of cognitions involved in moral injury can guide effective treatment planning. In particular, the most recent diagnostic criteria for posttraumatic stress disorder is used to distinguish the objectively falsifiable descriptive cognitions often associated with trauma from the subjectively determined prescriptive cognitions that characterize moral injury. Scenarios from war zone deployments have been used to highlight the relevance of this distinction for moral injury, and a general treatment framework that shows how existing and novel interventions may complement one another is presented. Research suggestions for assessing descriptive and prescriptive cognitions in moral injury and empirically validating this treatment framework are discussed.

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Implementing Cognitive Processing Therapy for Posttraumatic Stress Disorder With Active Duty U.S. Military Personnel: Special Considerations and Case Examples

Cited by 32 publications

References 30 publications

Development and evaluation of the Expressions of Moral Injury Scale—Military Version

Development and evaluation of the Expressions of Moral Injury Scale—Military Version

The Impact of Military Status on Cognitive Processing Therapy Outcomes in the Community

Is and Ought: Descriptive and Prescriptive Cognitions in Military‐Related Moral Injury

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