PROFESSIONALS’ PERSEPECTIVES ON HOW VETERANS MANAGE
TRAUMA IN THE CONTEXT OF PTSD
A Project
Presented to the faculty of the Division of Social Work
California State University, Sacramento
Submitted in partial satisfaction of
the requirements for the degree of
MASTER OF SOCIAL WORK
by
Catherine Brown
Julia Holzapfel
SPRING
2013
PROFESSIONALS’ PERSPECTIVES ON HOW VETERANS MANAGE TRAUMA
IN THE CONTEXT OF PTSD
A Project
by
Catherine Brown
Julia Holzapfel
Approved by:
__________________________________, Committee Chair
Dale Russell, Ed.D., LCSW
____________________________
Date
ii
Students: Catherine Brown
Julia Holzapfel
I certify that these students have met the requirements for format contained in the
University format manual, and that this project is suitable for shelving in the Library
and credit is to be awarded for the project.
__________________________, Division Director___________________
Robin Kennedy, Ph.D.
Date
Division of Social Work
iii
Abstract
of
PROFESSIONALS’ PERSPECTIVES ON HOW VETERANS MANAGE TRAUMA
IN THE CONTEXT OF PTSD
by
Catherine Brown
Julia Holzapfel
The present study conducted exploratory research examining the relationship between
positive and negative coping styles utilized by veterans diagnosed with PTSD to
manage trauma. Variations in coping styles were studied in association to outcomes of
both symptom severity and social functioning. Social functioning was measured by a
modified version of the Social Functioning Questionnaire, and PTSD symptom
severity was measured by a modified version of the PTSD Checklist-Military Version.
The sample included 33 professionals in various mental health settings who have
treated veterans with a PTSD diagnosis within the last ten years. The findings
represent their perspectives on how veterans’ manage trauma. Overall findings suggest
an association between positive coping styles, higher levels of social functioning, and
lower PTSD symptom severity. Negative coping styles were associated with lower
levels of social functioning and higher levels of PTSD symptom severity. Negative
coping included the following coping styles; anger and dissociation, behavioral
avoidance, cognitive avoidance, risk-taking behaviors, substance use, and suicidal
iv
ideations. Positive coping styles included; positive behavioral approaches, selfnarratives, PTG, religious/spiritual coping, and social support. The findings of this
study hold relevance to the treatment of trauma and PTSD in the veteran population.
The data emphasizes the importance of incorporating positive coping techniques into
mental health treatment of veterans diagnosed with PTSD.
__________________________________, Committee Chair
Dale Russell, Ed.D., LCSW
_______________________
Date
v
ACKNOWLEDGEMENTS
We would like to dedicate this project to our parents; Cynthia Brown & Cliff
Brown, Lynn Leonardi & Howard Holzapfel. Thank you for your support in the
completion of our education. A special thanks to our fathers who are both Veterans.
vi
TABLE OF CONTENTS
Page
Acknowledgments....................................................................................................... vi
List of Tables ................................................................................................................ x
List of Figures ............................................................................................................. xi
Chapter
1. STATEMENT OF THE PROBLEM .........................................................................1
Background of the Problem ............................................................................ 2
Statement of the Research Problem ................................................................ 4
Study Purpose ................................................................................................. 5
Theoretical Framework .................................................................................. 6
Definition of Terms ........................................................................................ 8
Assumptions ................................................................................................. 10
Social Work Research Justification .............................................................. 12
Study Limitations ......................................................................................... 12
Statement of Collaboration ............................................................................ 13
2. REVIEW OF THE LITERATURE ........................................................................ 14
Anger and Dissociation ................................................................................... 15
Cognitive and Behavioral Avoidance ............................................................. 17
Post Traumatic Growth ................................................................................... 20
Positive Behavioral Approaches ..................................................................... 22
vii
Processing Trauma with Self-Narratives ........................................................ 23
Social Support and Context ............................................................................ 25
Military Culture and Implication on Trauma .................................................. 29
Substance Abuse ............................................................................................ 30
Risk Taking Behaviors .................................................................................... 33
Suicidal Ideations and Attempts ..................................................................... 35
Spiritual Well-being and Religious Coping .................................................... 37
3. METHODS ............................................................................................................. 40
Study Objectives ............................................................................................ 40
Study Design ....................................................................................................41
Sampling Procedures .......................................................................................41
Data Collection Procedures..............................................................................42
Instruments .......................................................................................................43
Data Analysis ...................................................................................................43
Protection of Human Subjects .........................................................................45
4. STUDY FINDINGS AND DISCUSSIONS ........................................................... 48
Overall Findings.............................................................................................. 48
Specific Findings ............................................................................................ 50
Interpretations of the Findings ........................................................................ 62
Summary ......................................................................................................... 63
5. CONCLUSION, SUMMARY AND RECCOMENDATIONS .............................. 65
viii
Summary of Study .......................................................................................... 65
Implications for Social Work .......................................................................... 65
Recommendations ........................................................................................... 69
Limitations ...................................................................................................... 72
Conclusion ...................................................................................................... 74
Appendix A. Human Subjects Review Approval Letter ............................................ 75
Appendix B. Introduction Letter and Consent to Participate ...................................... 76
Appendix C. On-line Survey....................................................................................... 79
References ................................................................................................................. 118
ix
LIST OF TABLES
Tables
Page
1.
Table 1 One way frequency table of demographics.......................................... 49
2.
Table 2 Descriptive statistics of symptom severity, by coping type and coping
style .................................................................................................................. 51
3.
Table 3 Estimated marginal means of coping styles, symptom severity ......... 53
4.
Table 4 Descriptive statistics of social functioning, by coping type and coping
style .................................................................................................................. 57
5.
Table 5 Estimated marginal means of coping styles, social functioning……..59
x
LIST OF FIGURES
Figures
1.
Page
Figure 1 Box plot of the composite scores of symptom severity by coping
type ................................................................................................................... 52
2.
Figure 2 Box plot of the composite scores of social functioning by coping
type ................................................................................................................... 53
3.
Figure 3 Box plot of the composite scores of symptom severity by coping
style .................................................................................................................. 58
4.
Figure 4 Box plot of the composite scores of social functioning by coping
style .................................................................................................................. 60
5.
Figure 5 QQ plot for symptom severity ........................................................... 61
6.
Figure 6 QQ plot for social functioning ........................................................... 62
xi
1
Chapter 1
STATEMENT OF THE PROBLEM
Imagine being at home watching a movie with your family and suddenly a large
boom reverberates from the speakers of the TV. The room quickly fades away as another
reality invades your mind. Explosions everywhere, smoke, screaming voices, and
scattered body parts across the road. Fear sets in with a racing heart, sweaty palms,
difficulty breathing, and the urge to find safety. You gasp in horror and as you hear the
sound of your wife’s voice saying, “honey, are you okay?” the living room fades back
into existence. This experience holds particular relevance to the veteran population who
are often exposed to numerous physical and psychological traumas throughout their
military service. Consequently, a large percentage of individuals who are exposed to
physical and psychological traumas develop Post-Traumatic Stress Disorder (PTSD); an
anxiety disorder that develops from events which are defined as traumatic and result in
feelings of “fear, hopelessness, or horror” (Seides, 2010, p. 725).
Veterans handle trauma in a variety of ways, for some a traumatic experience
provides an opportunity for growth, while it can lead to maladaptive behaviors and
symptoms for others. Due to the capacity for trauma inherent in the veteran population,
combined with high numbers of veterans returning to civilian life after the end of the Iraq
and Afghan Wars; the researchers chose to focus the study on “professionals’
perspectives on how veterans manage trauma in the context of Post-Traumatic Stress
Disorder (PTSD).” The sheer number of veterans who will experience mental health
2
difficulties upon their return home is indicative of the relevance and importance of this
topic.
Background of the Problem
PTSD in the veteran population is an established problem that has been
researched extensively in recent years. One compelling study found that of the estimated
two million veterans returning home from Iraq and Afghanistan around 20 percent will
experience PTSD or depression upon return to civilian life (Rudd, Goulding, & Bryan,
2011). In addition, research has established that combat exposure is a significant risk
factor for the development of PTSD. This suggests the importance of this topic for the
veteran population, who often engage in direct combat throughout their military service.
In fact, one study found a relationship between combat related trauma exposure, PTSD,
Major Depressive Disorder, substance abuse, unemployment and job loss, marital
problems, and domestic violence (Prigerson, Maciejewski, & Rosenheck, 2002).
The recent influx of veterans attempting to reintegrate into civilian life has
prompted researchers to look more closely at PTSD and the effects of trauma. It has
become clear that many of the individuals exposed to trauma during their military
service, now have mental health difficulties as they reintegrate into society.
Unfortunately, only one third of veterans struggling with PTSD are receiving “minimally
adequate treatment” for their trauma, demonstrating the scope and breadth of this issue
(Strachan, Gros, Ruggiero, Lejuez, & Acierno, 2012, p. 561). As demonstrated above, the
psychological impact of war is a relevant topic to modern American society.
3
Understanding how veterans cope with trauma is important and vital in creating effective
treatments and outreach efforts to those who may otherwise remain unacknowledged.
In order to understand why this issue is a problem, one must first gain an
understanding of the impact a diagnosis of PTSD can have on an individual’s life. The
diagnostic criteria for PTSD define a traumatic experience as an experience or event that
“includes the experience of a major threat to one’s life or one’s physical integrity”
(Seides, 2010, p. 725). Furthermore, PTSD is associated with “functional impairment,”
resulting in high rates of depression, anxiety, challenges readjusting to civilian life,
unemployment, marital issues, problematic substance abuse, and anger control problems
(Strachan et al., 2012, p. 560). As demonstrated above, PTSD affects many aspects of a
veteran’s life and overall well-being. The effects of this disorder in combination with
maladaptive coping patterns utilized in response to trauma can create long lasting
implications for the veteran population.
It is important to note that PTSD can stem from various types of trauma and exists
in several different populations of individuals in addition to veterans. Some alternative
forms of trauma which can lead to PTSD are as follows; domestic violence, physical and
sexual assault, acts of terrorism, natural disasters, incarceration, severe physical health
issues (e.g. heart attack), combat, and accidents (e.g. motor vehicle accident) (Carey,
2012). September 11, 2001 is a relevant example of a national event, which affected
many people and may have caused PTSD in those who survived, witnessed, or lost a
loved one in the attacks. Another example of a natural disaster in which people may have
developed PTSD is Hurricane Katrina. While the exact cause of PTSD is unknown,
4
several factors are considered when examining PTSD; including biological, social, and
psychological. Although our research primarily focuses on veterans with PTSD, the
disorder can potentially develop in any individual who has experienced a traumatic event
(Carey, 2012).
Statement of the Research Problem
The main question propelling the authors’ research is, “differential coping styles and
their outcomes within the context of PTSD in the veteran population.” The central issue
of this study is the exploration of coping styles associated with positive outcomes for
trauma exposed veterans. Positive and negative coping styles will be examined through
measurements of social functioning and PTSD symptom severity. In order to obtain data
the researchers distributed surveys to professionals who work with the veteran
population. The exploration of coping styles utilized in the face of trauma are relevant to
the veteran population because differential coping styles contribute to co-morbid
diagnoses, low levels of social functioning, and increased PTSD symptom severity.
Accordingly, diagnoses of PTSD have been linked with several negative
outcomes. For example, one study found that Vietnam War veterans with a diagnosis of
PTSD were almost 50 percent less likely to be employed (Erbes, Kaler, Schult,
Polusny, & Arbisi, 2011). In addition, men who are in active duty combat positions show
a higher risk of suicide when compared to their civilian counterparts (Rudd et al., 2011).
The above finding is one example of the relationship between exposure to trauma and
maladaptive coping. Lastly, Cucciare, Darrow, & Weingardt (2011) found that younger
veterans (18-25) tend to use alcohol and drugs as method of coping with symptoms of
5
PTSD and depression, and are twice as likely to engage in binge drinking when compared
to their civilian peers. These findings have obvious implications for the successful
reintegration of young veterans into civilian life.
Study Purpose
The purpose of this study is to understand the impact that different styles of
coping have on veterans’ ability to function with a diagnosis of PTSD from the
perspectives of professionals who work with this population. It is hoped that this
understanding will assist professionals in providing effective interventions to veterans
with trauma related psychological disorders. Researchers tend to focus on negative
coping styles and effects of trauma while ignoring possible positive outcomes and healthy
coping methods. For example, Post-Traumatic Growth (PTG) is a positive psychological
response, which often contributes to better outcomes for veterans who are managing
trauma (Benatato, 2011). While it is important for practitioners to understand negative
coping styles for managing trauma, it is equally important for positive coping styles to be
recognized and researched. By gaining a broader understanding of adaptive coping styles,
we can increase outreach efforts to the influx of young veterans returning home from Iraq
and Afghanistan.
The results of this study may prompt suggestions for improved interventions and
treatment outcomes, as veterans’ issues pose a unique challenge to the health of our
society as a whole. As large numbers of young veterans return home after exposure to
psychological and physical trauma, it is important to understand how they cope with
these experiences. Prior research of Vietnam veterans has shown many negative
6
associations between trauma and societal integration. By gaining a broader understanding
of these interactions, the researchers hope that professionals can craft more effective
treatment interventions to ensure that current and future generations of veterans are not
bound to this same fate.
Introduction to Research Methods
The study uses quantitative methods and is exploratory and descriptive in nature,
aiming to find out more about the different coping styles which trauma exposed veterans
utilize. The authors’ are investigating the relationship between many variables including
exposure to trauma, coping styles, treatment outcomes, and mental health. The
independent variable being examined is differential coping styles and the dependent
variables in this study are the levels of post-deployment social functioning and PTSD
symptom severity. The measurement of social functioning is based on professionals’
perspectives of factors such as the veterans’ socioeconomic status, employment,
substance abuse patterns, physical and mental health, relationships, and educational
attainment. PTSD symptom severity is measured using several criteria from the PTSD
Symptom Checklist-Military Version.
Theoretical Framework
The Ideologies and Values That Are Associated With the Problem
An overarching ideology that contributes to the problem is the concept of a
“military identity,” a value held by individuals in the military. Military identity and
culture must be adopted in order for soldiers to successfully integrate into military life;
however, upon reintegration to civilian society, these values can hinder mainstreaming
7
and a successful transition (Demers, 2011). Cultural norms and values that exacerbate
this issue consist of dehumanization, emotional detachment, selflessness, conformity, and
submission (Demers, 2011). This mindset often leads to veterans’ detaching themselves
from their true emotions, which negatively impacts their reintegration into society upon
their return to civilian culture. In addition to cultural and societal factors, theoretical
frameworks such as the psychobiology of trauma help explain this problem.
Many researchers have examined the psycho-physiological response to trauma,
particularly in individuals with PTSD. Biological changes in the brain, which occur
because of trauma and chronic stress, inhibit individuals’ ability to regulate their affect
and access traumatic memories when they are not in an aroused state (Briere & Scott,
2006). An understanding of how the brain responds to trauma is important in developing
holistic and effective approaches to the treatment of trauma survivors. Trauma and
danger activate an ancient the part of the brain (amygdala) which is in charge of flight or
fight responses (Briere &Scott, 2006). This response is usually activated in reaction to
situational dangers and provides the body with the necessary physiological reactions to
either fight or run away from dangerous stimuli in a timely manner. At one point in time,
this response was adaptive because it enabled our predecessors to survive dangerous
situations. However, it often becomes a cued and maladaptive response for those who
have experienced trauma (Briere &Scott, 2006).
Individuals with PTSD often develop hyper-arousal and maladaptive behaviors
like “freezing” because a stress response is activated when the person is in a safe
environment. Many situations which trauma exposed individuals encounter can trigger
8
this response, because it is no longer conditioned to specific dangerous situations such as
gunfire or an incoming shell. When individuals experience chronic stress and hyperarousal via the fight or flight response, chemical changes occur in the brain, which can
affect memory, reasoning, and executive functioning; all of which are associated with
PTSD (Briere & Scott, 2006).
As aforementioned, stress often occurs in individuals diagnosed with PTSD
because they experience hyper-arousal in association with sensory information related to
the trauma they experienced. This learned association ties thoughts, images, and sounds
to stress responses such as increased heart rate, blood pressure, galvanic skin response,
and other symptoms of anxiety (Briere & Scott, 2006). When this association occurs in
situations, which are encountered on a daily basis, it poses a problem. In sum, memories
of traumatic events are stored in somatic memory because conditioned responses pair
trauma related thoughts and emotions to arousal and anxiety (Briere & Scott, 2006). This
biological process of the activation of traumatic memories impacts the overall
symptomology and functioning of individuals with PTSD.
Definition of Terms
The researchers are exploring how veterans manage trauma within the context of
PTSD as defined by the DSM-IV. The DSM-IV criteria of PTSD is as follows; following
exposure to a traumatic event an individual must meet both specifications of criterion A
which states that, “The person has experienced, witnessed, or been confronted with an
event or events that involve actual or threatened death or serious injury, or a threat to the
physical integrity of oneself or others.” Furthermore, “The person’s response involved
9
intense fear, helplessness, or horror.” In addition, the individual must experience
symptoms from each of the three symptom clusters; at least one symptom from “intrusive
recollection,” at least three symptoms from “avoidant/ numbing,” and at least two
symptoms from the “hyper-arousal” cluster. Lastly, criterion F is concerned with the
individuals “functional significance” within society (APA, 2000, p. 456). The duration of
the symptoms experienced from these three clusters must last longer than one month as
stated in criterion E.
Clearly defining terms and creating survey questions that are concise and free of
bias, can contribute to increased reliability and validity of the study. Accordingly, the
authors intend to increase reliability and validity by defining each variable and avoiding
ambiguous or biased wording in the survey. There are several variables in this study
including 17 PTSD symptom severity criteria, 11 coping styles, and 16 criteria to
measure the level of social functioning. For the purpose of this project the veteran sample
includes any U.S. veteran diagnosed with PTSD (as a result of war trauma) which
professionals have treated in a mental health setting within the past ten years. PTSD can
be defined as a diagnosis/ positive screen or provisional diagnosis/ positive screen of
PTSD as defined by the DSM-IV above. Coping styles are defined as the way in which
the veteran responds to the psychological trauma they have experienced; and can be
viewed as either adaptive or maladaptive. There are a total of 11 coping styles which are
discussed in greater detail in the following chapters. Lastly, the concept of social
functioning is defined by the veterans’ level of integration into society in terms of their
10
socioeconomic status, employment, substance abuse patterns, physical and mental health,
relationships, and educational attainment.
Assumptions
Hypothesis/ Expected Findings
The authors’ propose that positive coping styles will be associated with higher
levels of social functioning and less severe PTSD symptoms and chronicity. On the other
hand, the authors’ hypothesize that negative coping strategies will be associated with
lower levels of social functioning and more acute PTSD symptomology. The authors
hope to identify the variables that are most conducive to successful outcomes for trauma
exposed veterans. This information can be incorporated into best practices for the
treatment of PTSD. Contributing to the body of research related to the management,
maintenance, and extinction of Post-Traumatic Stress will benefit veterans’ social
functioning and mental health status. In addition, the researchers hope to highlight
positive coping styles, which are assumed to often be overlooked by practitioners who
tend to focus on the more common negative symptoms of trauma. The researchers hope
that this will prompt practitioners to incorporate psycho-educational material and
interventions that utilize positive coping methods into their practice.
One study suggests that many interventions simply focus on “symptomatic relief
to life functioning” while ignoring some positive growth that has the potential to occur in
treatment (Tsai, Harpaz-Rotem,Pietrzak, and Southwick, 2012). The authors of the
current study assume that exploring positive coping styles will lead to a higher
occurrence of adaptive coping style such as PTG, as opposed to treatment that focuses
11
solely on relieving the immediate symptoms of PTSD (nightmares, flashbacks, etc) in the
veteran population.
Data Collection from Similar Studies
The researchers base their assumptions on previous findings from studies
exploring similar topics. One such study conducted among Israeli veterans investigated
the relationship between active and avoidant coping styles and self-efficacy; comparing
soldiers with and without a positive screen for PTSD (Galor, & Hentschel, 2012). Similar
to the authors’ hypothesis for this study, the PTSD group scored considerably lower on
all variables including self-efficacy. A main difference between the two studies is the
population being examined, and the dependent variable of self-efficacy vs. social
functioning and symptom severity.
Another relevant study examined the relationship between PTSD and social
functioning among veterans. Specifically, the authors’ examined the association between
social context (social support, interpersonal relationships, and functioning) and the
severity of PTSD. Both studies examined the connection between PTSD symptom
severity and social functioning; however, the current study uses coping styles as the
independent variable and social functioning and symptom severity as the dependent
variables. Instead of social context acting as a mediator of PTSD severity, the current
study proposes that coping styles will mediate PTSD severity and social functioning (Tsai
et al., 2012). While several studies examine similar variable, there is a lack of literature in
regards to positive and negative coping styles and the outcomes that are predicted among
trauma exposed veterans in the United States.
12
Social Work Research Justification
This study holds potential utility within social work practice because it will
provide insight on adaptive and maladaptive coping techniques employed in response to
trauma. The information gained from this data can be used by practitioners to improve
the efficacy of treatments for veterans with PTSD. This study will offer an important
contribution to the field of social work and will benefit government and nonprofit
organizations such as Veterans Affairs and The American Legion, who manage the
mental health and health care of veterans. Knowledge of adaptive and maladaptive
coping styles can be used to create groups or educational classes designed to teach
returning combat veterans healthy ways to manage the stress of the trauma that they
experienced.
Study Limitations
A major limitation of this study is the sample surveyed. Rather than gathering
data directly from veterans, this study surveyed professionals who work with the veteran
population. Furthermore, the sample size of the study (N=33) is not large enough to
generalize the findings to all professionals who work with veterans. Due to the nature of
online data collection; self-reported information is naturally biased. Additionally, the
researchers rely on the honesty of the participants in reporting their demographic
information, qualifications, and report of their professional experiences. Another limiting
factor is that most professionals in mental health settings have experience with clients
who are in acute stress. Therefore, many of the veterans who are coping well with their
13
traumas may be overlooked. This may result in an unequal distribution of responses for
negative and positive coping styles.
Statement of Collaboration
This project and all data collected was a collaborative process between the
researchers, Catherine Brown and Julia Holzapfel.
14
Chapter 2
REVIEW OF THE LITERATURE
It would be meritless to do further research on this topic without exploring the
extensive data that already exists regarding PTSD symptom severity, social functioning,
and contributing coping styles utilized by veterans in the face of trauma. Individuals react
in varying ways when managing psychological and physical pain from trauma. These
differences support the need to analyze differential coping styles used by veterans in
response to trauma. Veterans in particular are at increased risk for developing PTSD and
experiencing challenges with social functioning and reintegration, due to their exposure
to high levels of trauma. Variations in the management of trauma result in different
coping styles, both adaptive and maladaptive.
In exploring and analyzing the current literature regarding veterans living with
PTSD, 11 groups of common coping styles were found; including anger and dissociation,
behavioral avoidance, cognitive avoidance, substance abuse, suicidal ideations and/or
attempts, risk-taking behaviors, Post-Traumatic Growth (PTG), positive
religious/spiritual coping, positive behavioral approach strategies, use of self-narratives,
and social support. Differential coping methods are associated with various outcomes in
both severity of PTSD symptoms and level of social functioning for veterans upon their
return home; therefore, it is essential that there is better understanding of emotion
processing and outcomes of specific coping styles regarding the development and
management of PTSD among treatment-seeking veterans.
15
Anger and Dissociation
Two emotion-related outcomes, anger and dissociation, are key factors in the
development and maintenance of PTSD. There is a strong relationship between military
combat veterans and anger and dissociation. Furthermore, these two factors were found to
be significant predictors of the severity of PTSD (Kulkarni, Porter & Rauch, 2011).
Anger and dissociation were evaluated using diagnostic interviews, which were a
combination of professionals’ perspectives and self-report questionnaires by veterans
(Kulkarni et al., 2011). The level of anger was a key aspect in determining veterans with
and without PTSD (Kulkarni et al., 2011). Higher levels of dissociation during and
following trauma were found among those with PTSD when compared to those without a
diagnosis (Kulkarni et al., 2011).
Anger and dissociation are two key factors related to trauma that produce
problematic coping styles and emotional avoidance among veterans with PTSD. Anger
and dissociation appear to “be complimentary problematic coping strategies related to
higher PTSD severity” (Kulkarni et al., 2011, p. 274). Another study with a similar
outcome grouped veterans by levels of PTSD symptomatology and compared traits of
anger, hostility, and aggression (Jacupkak, Conybeare, & Phelps, 2007). Veterans who
were diagnosed with PTSD reported significantly greater anger, hostility, and increased
aggression than those in non-PTSD groups (Jacupkak et al., 2007). Coping styles such as
anger and dissociation can predict varying outcomes related to the maintenance of PTSD.
Accordingly, this coping style is important to consider in the current study.
16
Anger is a form of avoidance that veterans with PTSD may utilize in order to gain
a sense of control over their situation (Kulkarni et al., 2011). As a result of the violence
experienced while at war, veterans often experience pervasive feelings of guilt when they
return home. Disengaging from these feelings is a common method of coping with these
intrusive feelings of guilt and shame. However, data show that by avoiding these feelings,
symptom severity increases (Held, Owens, Schumm, Chard, & Hansel, 2011). On the
other hand, when an individual acknowledges these feelings and embraces the notion of
forgiveness and acceptance, a better outcome is often experienced (Witvliet, Phipps,
Feldman, & Beckham, 2004).
Anger is an “active avoidance” coping strategy in which veterans employ a false
sense of control over their environment. Behaving angrily allows individuals to feel like
they are not only impacted by the trauma, but are actively dealing with their trauma
(Kulkarni et al., 2011). Anger is also seen as more acceptable in American culture in
comparison to fear and vulnerability. Dissociation is similar because it is an “active
avoidance” strategy that provides a false sense of control by removing the person from
their stressful emotions and pulling them away from their memories of the emotional
trauma (Kulkarni et al., 2011, p. 276). Assessment of anger and dissociation in PTSD can
be used to produce better treatment planning, by providing mental health professionals
with an awareness of outcomes regarding anger and dissociation as avoidance strategies
(Kulkarni et al., 2011). The above coping methods were defined by the veterans’
perspectives using self-report measures, as there is limited research done from
professionals’ perspectives on how veterans manage trauma.
17
Cognitive and Behavioral Avoidance
Veterans who screen positive for PTSD often develop nuanced methods of coping
with war related trauma. A common method of coping is avoidance, which has been
linked to negative outcomes, such as hindering social support and integration (Mattocks,
Haskell, Krebbs, Justice, Yano & Brandt, 2011; Pietrzak, Harpaz-Rotem, & Southwick,
2011; Kulkarni et al., 2011). This avoidance can be either cognitive or behavioral,
affecting the way in which veterans manage their thoughts or behaviors. These behaviors
and thoughts can result in various forms of avoidance including; disengagement,
withdrawal and detachment from thoughts and feelings, increased thoughts of guilt, and
decreased ability to manage these feelings (Kulkarni et al., 2011). Substance abuse is
another form of disengagement and coping where veterans distance themselves from their
feelings. It is important to understand and investigate the differing ways that veterans
manage trauma, due to the established relationship between increased PTSD severity and
avoidance techniques often utilized by veterans with PTSD.
Gender Differences in Avoidance Patterns
Cognitive and behavioral processes in men and women contribute to differences
in coping styles in the management of trauma among veterans. Accordingly, significant
differences are seen among males and females in the way that they address and manage
stressors. In one study, these differences were measured by surveys and the data collected
was from the veterans’ perspectives. Women veterans identified two major stressors from
war; stressful military experiences and post-deployment reintegration problems, which
resulted in three major coping strategies (Mattocks, et al., 2011). Behavioral avoidance,
18
cognitive avoidance, and behavioral approaches were three coping styles consistently
identified among women veterans (Mattocks et al., 2011). Both male and female veterans
reported behavioral avoidance coping strategies. Similar to “active avoidance” strategies
discussed above, behavioral avoidance allows women to engage in behaviors that replace
stressful feelings and memories related to deployment with other forms of satisfactions
(Mattocks et al., 2011).
Although behavioral avoidance is common among both male and female groups,
female soldiers are less likely to develop substance use problems than men (Larson,
Wooten, Adams & Merrick, 2011). Male veterans often depend on alcohol to cope with
stress and trauma, whereas female veterans in this study did not constantly rely on
alcohol, smoking, or drug use as mechanisms for coping with stress (Mattocks et al.,
2011). However, women are more likely to screen for PTSD and depressive symptoms
than men (Larson et al., 2011). Furthermore, one characteristic of cognitive avoidance
coping reported by women was the engagement of activities in isolation (Mattocks et al.,
2011). This is commonly demonstrated by isolating from family and friends in both male
and female veterans (Mattocks et al., 2011).
Types of Cognitive and Behavioral Avoidance
There are many forms of cognitive avoidance used in an attempt to control
distressing thoughts related to trauma. A 1994 study by Wells and Davies identified six
types of thought control coping strategies used in the face of trauma including; “worry,
self-punishment, re-appraisal, cognitive distraction, behavioral distraction, and social
control” (Pietrzak et al., 2011, p. 252). Furthermore, both cognitive and behavioral
19
avoidance are linked to increased severity of PTSD. In addition, a study of Gulf War
veterans found a positive association between avoidance demonstrated during an initial
post-deployment medical evaluation and PTSD symptom severity 10-13 months
afterwards (Pietrzak et al., 2011).
Although findings suggest that avoidance is linked with increased severity of
PTSD in both symptomology and chronicity, little research has been done on these
specific behaviors and cognitive strategies (Pietrzak et al., 2011). Despite these gaps in
knowledge, one article suggests there are four specific types of avoidance strategies,
which include cognitive social, cognitive non-social, behavioral social, and behavioral
non-social. One example of cognitive social avoidance is an individual ignoring tension
and conflict in their marriage. An example of cognitive non-social avoidance is an
individual failing to think about issues such as future employment and finances. An
example of behavioral social avoidance is an individual who purposefully avoids social
situations and fabricates excuses to remain in isolation. Behavioral non-social avoidance
includes engaging in activities that condone isolation such as watching TV alone
(Pietrzak et al., 2011). The findings of this study suggest that veterans’ with PTSD are
more likely to use the avoidant cognitive-behavioral strategies discussed above, and this
in turn contributes to maladaptive coping which may impede their recovery from trauma
(Pietrzak et al., 2011). These findings suggest the importance of addressing social
avoidance when treating veterans with PTSD. Because many of the coping styles above
are linked to PTSD severity and social functioning, it is important to include them in the
current researchers’ study.
20
Disengagement coping is another strategy related to the severity of PTSD in a
sample of veterans. These coping styles were measured by self-reports and clinician
administered scales (Held et al., 2011). Trauma related guilt exists due to the nature of
war and associated violence, resulting in a positive association between levels of guilt
and severity of PTSD (Held et al., 2011). Higher “guilt-related cognitions” among
veterans result in disengagement coping strategies, which can also interfere with effective
treatment of PTSD (Held et al., 2011 p. 708). Disengagement coping strategies are
characterized by social withdrawal, denial, and disengagement from thoughts and
feelings regarding trauma (Held et al., 2011). Similar to the results associated with
disengagement coping strategies, studies also show negative outcomes when examining
factors such as not forgiving oneself and negative religious coping (e.g. anger at God).
Disengaging coping styles such as these result in anxiety, depression, and increases in
PTSD symptom severity (Witvliet et al., 2004). When veterans embraced forgiveness and
positive religious coping (e.g., benevolent religious appraisals), effective treatments were
enhanced (Witvliet et al., 2004). Identifying these different coping styles among veterans
is a critical part of effective treatment for PTSD. In addition to focusing on negative
forms of coping, it is important to explore healthier methods of coping in order to gain a
better understanding of adaptive coping with PTSD.
Post-Traumatic Growth
Several of the coping strategies discussed above focus on negative coping
mechanisms, but it is important to note that there are positive coping strategies as well.
These positive coping strategies are based on veterans’ perspectives of methods they have
21
used to manage trauma. In an under-studied phenomenon termed Post-Traumatic Growth
(PTG), some individuals experience growth rather than stress following exposure to
trauma, using positive rather than negative coping techniques to manage their stress
(Benetato, 2011; Mattocks et al., 2011; Sinclair, 2012). Interestingly, this growth is often
precipitated by utilization of direct methods of coping with the trauma experienced, and
less disengagement or avoidance coping. PTG is important to study because it
demonstrates the potential for positive self-discovery following trauma, giving veterans
hope and an alternative framework of coping with their PTSD (Benetato, 2011; Sinclair,
2012).
In a study of more than 600 trauma survivors, individuals reported positive
change in “five areas: they had a renewed appreciation for life; they found new
possibilities for themselves; they felt more personal strength; their relationships
improved; and they felt spiritually more satisfied” (Sinclair, p. 3, 2012). Experiencing
growth following a traumatic experience often co-exists with PTSD (Sinclair, 2012). It is
important to distinguish between negative and positive coping strategies because positive
coping strategies such as these will help produce better long-term outcomes and
interventions that will assist specific needs of veterans.
Research on veterans struggling with trauma tends to focus on PTSD and
depressive symptoms, but it is equally important to focus on PTG and the positive effects
of trauma that veterans’ experience (Benetato, 2011). According to the PTG model, there
are five components of PTG that a veteran can experience following a traumatic event
which include; personal strength, new possibilities, spiritual growth, understanding and
22
relating to others, and a new found appreciation for life (Benetato, 2011). This particular
coping style is not a direct result of the trauma experienced, but rather a slow process that
occurs during the veteran’s attempt to create a new positive “reality or personal
worldview” (Benetato, 2011 , p. 413). Through self-disclosure, rumination, and problem
solving, veterans strive for the creation of a new worldview that will allow for advantages
such as; reduced stress, controlled anger and emotions, and a decrease in disengagement
(Benetato, 2011). Positive coping styles are often overlooked by clinicians and understudied. Therefore, it is important to highlight them in the current study.
Positive Behavioral Approaches
One study in particular focused on women veterans and their utilization of
positive behavioral coping styles. These women often experienced great difficulty
readjusting to civilian life after deployment, but used positive behavioral approach
strategies to cope with this transition. The women used behavioral approaches to take
concrete actions to deal with their stress and used positive strategies to overcome
negative emotions (Mattocks et al., 2011). Unlike some of the women who pursued
isolation upon return, several women spoke of reaching out to others, coming together as
veterans, sharing experiences, and supporting each other (Mattocks et al., 2011). Women
viewed the opportunity to speak with others as a therapeutic experience that helped them
manage stress (Mattocks et al., 2011). Other positive strategies included relying on
regular routines, such as running, yoga, and meditation (Mattocks et al., 2011).
23
Processing Trauma with Self-Narratives
Several studies have investigated positive ways of coping with trauma through
storytelling, understanding PTSD within social constructs such as masculinity, and
through the creation of positive constructs of self-identity (Aiello, 2010; Benetato, 2011;
Fox & Pease, 2012; Stansbury, Mathewson-Chapman, & Grant, 2003). These coping
methods involve self-disclosure and acceptance of the trauma related experienced in
order to create a new positive identity post trauma. Additionally, many of these positive
coping strategies involve self-reflection either through storytelling, disclosure, or by
confronting their trauma in a supported environment. These methods differ from
avoidance strategies of coping because the veteran manages their distress by
acknowledging their trauma and incorporating it into their identity in a positive and
healthy manner (Aiello, 2010; Benetato, 2011; Fox & Pease, 2012; Stansbury,
Mathewson-Chapman, & Grant, 2003).
Narrative Coping and Gender Differences
One study examined the context and roles of gender and their influence on trauma
among veterans. Male experiences of trauma are less understood in the context of gender
than female experiences of trauma. Many studies focus on individual characteristics of
trauma, but this study examines the social construction of masculinity in relation to the
armed forces “gendered male culture” (Fox & Pease, 2012, p. 17). Ideas of what
constitutes “manliness” have long influenced male experiences of trauma (Fox & Pease,
2012). Another study focused on the impact of the “Veterans’ Cultural Model of
Masculinity,” finding a discourse of certain expectations for male veterans in regards to
24
“being a man” (Stansbury et al., 2003, p. 175). There is a “strongly moral normalizing
discourse” about masculinity that tends to separate gender roles. This discourse affects
the manifestation of PTSD symptoms and coping strategies in regards to gender
(Stansbury et al., 2003, p. 175).
Another study investigated “trauma wisdom,” a coping strategy in which veterans
explore the influences of masculinity by speaking of their experiences and developing a
new self-narrative (Fox & Pease, 2012, p. 28). This coping strategy allows male veterans
to replace failure experienced in response to the traumatic event as a failure in the social
construction of masculinity, not in the individual (Fox & Pease, 2012). This coping style
helps male veterans examine previous assumptions about “manliness” rather than have
the veteran re-conform to existing social norms (Fox & Pease, 2012). Examining
veterans’ perspectives and experiences regarding trauma on both individual and societal
levels allows for specific needs to be addressed and managed. An awareness of differing
coping strategies will produce more efficient long-term outcomes and effective
treatments for veterans.
Similar to the concept of “trauma wisdom,” the positive implications of
“mentalization and reflective functioning” by veterans’ narrative storytelling are seen in
another study (Aiello, 2010, p. 329). Violent and negative thoughts can be targeted when
analyzing veterans’ self-narratives and their stories, allowing externalization and the
removal of negative narratives from the veterans’ memory (Aiello, 2010). Veterans who
face their challenges and confront their trauma are able to see a “shattered worldview”
that can be re-constructed in a positive light (Benetato, 2011, p. 14). This type of
25
reflection pulls the violent thoughts outside of the veterans’ narrative and allows the
veteran to co-construct a new memory. Self-reflection provides veterans with a better
understanding of their issues, and allows them to process their problems and regulate
their emotions in a healthier way (Aiello, 2010). In addition, the veterans’ storytelling
assists clinicians in providing effective treatment because they are able to better
understand the veterans’ experiences and identity (Aiello, 2010). The process of coconstructing a new “self” in treatment with the veteran, allows the clinician to
“experience new pathways neurologically” to processing and acknowledging the
problems of the veteran (Aiello, 2010, p. 329). Furthermore, veterans found that telling
their stories to others was an effective form of treatment for them (Demers, 2011).
Social Support and Context
Several studies show that social support is an important mediator between PTSD
and healthy coping with trauma (Benetato, 2011; Pietrzak et al., 2011; Resnick, Bradford,
Glynn, Jette, Hernandez, & Wills, 2012). Common coping methods of PTSD such as
avoidance, disengagement, and withdrawal are not conducive to healthy social support
networks and can hinder recovery from trauma. On the other hand, if a veteran has a
strong social support network upon returning home and is supported by his or her peers,
the transition from soldier to civilian is less challenging (Resnik et al., 2012).
Recognizing the connection between social networks and symptom severity is important
because clinicians can tailor their interventions with veterans to focus on this protective
factor. For example, veterans who feel they are understood by their peers or who
participate in family based interventions have more positive outcomes when compared to
26
those who do not (Pietrzak et al., 2011; Resnik et al., 2012). Furthermore, individuals
who experience Post-Traumatic Growth and use positive coping styles often have a
stronger social support network and feel more understood by their peers (Benetato, 2011).
Social context and social support heavily influence the severity of a veteran’s
PTSD symptoms. In fact, one meta-analysis studying risk factors of PTSD concluded that
low social support following trauma was one of the strongest predictors of PTSD
development (Pietrzak et al., 2011). Furthermore, there is a negative correlation between
increased social support and PTSD, depression, and suicidal thoughts. This demonstrates
the important role that social contact and relationships may play in treating and
preventing PTSD following trauma (Pietrzak et al., 2011). In addition, there is a negative
association between veterans who feel that others understand their traumatic experiences,
and symptoms of PTSD. While this understanding often leads to alleviation of PTSD
symptoms, an adverse effect can also occur when veterans feel their peers do not
understand their experience. Subsequently, this is related to an increase in PTSD
symptom severity and a breakdown of social supports (Pietrzak et al., 2011).
Similar findings have been found regarding the benefit of social support in an
article that discusses the effectiveness of family based interventions and support
networks. For example, veterans who experienced depression in conjunction with PTSD
showed a reduction in symptoms following successful family based interventions;
emphasizing the positive implications of a strong social support network (Resnik et al.,
2012). A veteran’s social network is important in aiding their successful transition into
society. This is essential because in order to evaluate the effectiveness of coping
27
strategies, the veteran’s level of reintegration into society is often used as a measurement
of their overall functioning (Resnik et al., 2012). Furthermore, social contact is an
essential component of recovery because community integration depends on the veteran’s
social support system. Accordingly, unsuccessful social functioning and PTSD symptoms
increase when a veteran prefers to live in isolation (Resnik et al., 2012). On the other
hand, when a veteran embraces a productive social role in society, maladaptive coping
strategies such as avoidant behaviors are reduced (Resnik et al., 2012). One article found
that levels of distress were greatly increased when veterans were isolated from family,
friends, and other social support systems (Demers, 2011). In conclusion, a smooth
transition from soldier to civilian and maintaining an involved community membership
are key components of recovery from trauma.
Mediating Factors
Research suggests that Vietnam veterans with PTSD experience increased marital
conflict and divorce when compared to their peers without a diagnosis. As discussed
above, a strong social support network has been associated with decreased symptom
severity and positive life outcomes for veterans. Subsequently, it is important to
understand the factors that can mediate successful reintegration into society, family
cohesion, and ultimately social support. One article proposes that differential coping
styles and personal resilience may facilitate positive outcomes of social support and
reintegration (Tsai et al., 2012). The results of the study found that when compared to
veterans without a PTSD diagnosis, those who screened positive for PTSD had lower
rates of satisfaction in several areas of interpersonal relations. This included decreased
28
satisfaction with romantic partners, overall social functioning, family unity, and overall
contentment with their lives (Tsai et al., 2012). Veterans with PTSD scored lower on
scales measuring resilience and thought control, suggesting that these two factors may
mediate the relationship between PTSD, social reintegration, and social context (Tsai et
al., 2012). These results underscore the importance of positive coping styles and
successful reintegration into society including satisfaction with interpersonal
relationships. This is especially important since a strong social support network is
conducive to positive outcomes in PTSD symptomology and severity.
The positive effects of social support are also seen in the process of PTG.
Veterans develop positive coping methods such as personal strength and appreciation for
life faster in the process of PTG when they are offered assistance from friends, families
and professionals (Benetato, 2011). Furthermore, the process of PTG is greatly expedited
when veterans receive support from individuals who have struggled with traumatic
experiences themselves (Benetato, 2011). For example, receiving support from other
veterans is placed at a higher value, due to the fact that they have been through similar
experiences and are able to offer advice that is viewed as “credible” (Benetato, 2011, p.
414). Instrumental support (e.g. physical support) and emotional support (e.g. active
listening, comforting gestures) are two components of social support that aid veterans
coping with trauma (Benetato, 2011). These types of social support continue to increase
positive coping and assist with successful societal integration among veterans (Benetato,
2011). Since social support plays such an instrumental role in the effectiveness of
29
treatment outcomes in veterans with PTSD, the researchers will explore this coping style
in relation to social functioning and PTSD symptom severity.
Military Culture and Implications on Trauma
Veterans returning from active duty are transitioning from military to civilian
culture, which requires acceptance and adaptability on behalf of both the veteran and
their loved ones. In order to be successful in the military one must conform to the norms
of that culture, and sacrifice many things for the greater good. Sometimes this sacrifice is
the loss of a friend, a limb, distance from one’s family, or even the loss of one’s own life.
In order to thrive in this environment the military often encourages a separation from
person, emotions, thoughts, and actions. One of the most important values of this culture
is to execute orders without question, which may require forsaking their own moral or
religious values (Demers, 2011). The differences between these two cultures causes
somewhat of a “culture shock” for veterans when they return home. This in turn can
cause veterans to feel isolated from their old social networks, family members, and even
their own emotions. Because social support is such an important protective factor against
PTSD, this disconnect between the two cultures should be addressed by the military,
clinicians, and families to ease veterans’ transition (Demers, 2011, p. 162).
A “military identity” must be adopted in order for veterans to successfully
integrate into the military culture (Demers, 2011, p. 162). Cultural norms and values
prevalent throughout the military consist of “self-sacrifice, discipline, and obedience to
legitimate authority” (Demers, 2011, p. 162). This “military identity” often coincides
with a mindset of dehumanization which causes veterans to detach themselves from their
30
true emotions. Resultantly, veterans cope by “learning to turn their emotions off,” which
negatively impacts their reintegration into society upon their return home to another
culture. There are significant differences between civilian norms and military values,
causing a “civil-military cultural gap” for the veteran who is transitioning into civilian
society, resulting in a “crisis of identity” (Demers, 2011, p. 162). This disconnect aides
avoidant behaviors and thoughts, which contribute to negative outcomes as previously
discussed The results of the study found that when faced with this culture shock and
mental health difficulties, the use of personal narratives has been successful in producing
better mental health outcomes (Demers, 2011).
Substance Abuse
Substance abuse among veterans who screen positive for PTSD is an issue which
several authors have researched (Bonn-Miller, Vujanovic, Boden, & Gross, 2011; Larson
et al., 2011; Seal, Cohen, Waldrop, Cohen, Maguen, & Ren, 2011). Alcohol and
marijuana are among the substances that have been extensively studied as a means of
coping with PTSD. Interestingly, substance abuse is associated with increased PTSD
symptom severity and is a form of self-medication to cope with negative thoughts and
emotions (Bonn-Miller et al., 2011). Furthermore, substance abuse is associated with
many maladaptive behaviors such as violence, and other risk taking behaviors (Strom,
Leskeia, James, Thuras, Voiier, Weigei, Yutsis, Khayiis, Lindberg, & Hoiz, 2012). The
connection between substance abuse and trauma is demonstrated by research showing
that with each deployment, veterans are more likely to develop a substance abuse
disorder (Larson et al., 2011).
31
Bremner et al., (1996) found that among Vietnam veterans with PTSD there was a
positive correlation between the amount of marijuana use and symptom severity (BonnMiller et al., 2011). The veterans involved in this study reported that they used marijuana
to cope with symptoms caused by their trauma (nightmares, re-occurring thoughts, etc.).
One similar study decided to probe deeper into understanding why trauma exposed
individuals with more severe symptoms tend to use marijuana as a method of coping
(Bonn-Miller et al., 2011). A variety of theoretical frameworks have suggested that
individuals who lack strong emotion-regulation skills alternatively engage in behaviors
aimed to reduce their psychological and physical discomfort. As a result, a correlation
among individuals who have experienced trauma and use marijuana as a means to cope
with their symptoms, and poor emotional-regulation of “affective states” is suspected
(Bonn-Miller et al., 2011, p. 35).
The above study confirmed that individuals with more severe PTSD symptoms
tend to engage in higher rates of “coping oriented” marijuana use (Bonn-Miller et al.,
2011, p. 37). In addition, the study found a statistically significant positive correlation
between PTSD symptom severity and difficulty with emotional regulation. A positive
association between poor emotional regulation and higher coping oriented marijuana use
was also found. Accordingly, the authors’ proposed that a program which promotes
emotional regulation among trauma exposed individuals would decrease the need for
substance oriented coping (Bonn-Miller et al., 2011). This information is helpful in
crafting interventions for trauma exposed individuals with substance abuse problems.
32
Substance Use and Military Demographics
A study by Hoge (as cited in Larson et al., 2011) found that the circumstances of
the OEF and OIF wars have led to a number of problems among returning veterans
including increased substance abuse, PTSD, and physical traumas. This increase can be
partially attributed to the extended duration of these wars and the high probability that
soldiers will be deployed numerous times. A study by Spera et al., (as cited in Larson et
al., 2011) found that with each additional year of deployment the odds of alcohol abuse
increased by 23%. Wilk et al., (as cited in Larson et al., 2011) established a positive
correlation between veterans’ amount of exposure to severe combat trauma such as death
or injury, and their level of alcohol abuse. Jakupcak et al., (as cited in Larson et al., 2011)
found a strong relationship between PTSD, depression, and alcohol abuse; reporting that
OEF and OIF veterans who screened positive for these disorders were two times more
likely to report alcohol abuse compared to veterans without these diagnosis.
Consistent with the studies above, one article found that veterans with PTSD were
3-4.5 times more likely to cope with their disorder by using drugs and alcohol (Seal et al.,
2011). Alcohol Use Disorder (AUD) and Drug Use Disorder (DUD) are prevalent
diagnoses among Iraq and Afghanistan veterans upon return, and there are high rates of
comorbidity of these disorders in the context of PTSD (Seal et al., 2011). Several studies
have found consistent findings that “self-medication” of PTSD symptoms increases
comorbidity with Substance Use Disorders (SUD) (Seal et al., 2011, p. 94). Furthermore,
this has proved to be significant among male veterans in comparison to female veterans.
Accordingly, the study found that 73% of male Vietnam veterans had a life-long
33
diagnosis of AUD with a comorbid diagnosis of PTSD and were 1.5-2 times more likely
than females to receive both AUD and DUD diagnoses (Seal et al., 2011). Veterans with
a PTSD diagnosis are at higher risk of AUD and were found to be four times more likely
to receive an AUD diagnosis and three times more likely to receive a DUD diagnosis
(Seal et al., 2011). Prior studies support these statistics by stating that veterans with
PTSD are three to four times more likely to be diagnosed with AUD and DUD (Seal et
al., 2011). In addition, PTSD symptoms were found to increase or intensify drug and
alcohol abuse, confirming that “psychiatric symptoms drive substance abuse in the
context of PTSD” (Seal et al., 2011, p. 98). Due to the implications of the above research
regarding the effects of substance abuse on social functioning and PTSD symptom
severity, the researchers will examine this method of coping as a variable in the current
study.
Risk-Taking Behaviors
Among the veteran population, risk-taking behaviors have been positively
correlated with both PTSD symptom severity and higher degrees of trauma exposure
(Strom et al., 2012). Risk-taking is a broad term that includes many different behaviors.
However, these behaviors usually share certain characteristics such as being socially
unacceptable and contributing to social isolation and withdrawal. For example, the
following risk-taking behaviors; elevated levels of substance abuse, violence, aggression,
weapon possession, and weapon related violence are related to PTSD symptom severity
and hinder social integration. Suicidal ideation and completions are another example of
risk-taking behaviors seen among trauma exposed veterans. In fact, OIF/OEF veterans
34
are at a higher risk for suicide when compared to both the general population and
veterans from other war cohorts (Strom et al., 2012).
Several theories attempt to postulate why veterans exposed to trauma may engage
in risky behavior. One theory proposes that trauma affects information processing
because it “narrow[s] people’s attentional band” making them more susceptible to risky
behaviors (Strom et al., 2012, p. 390). Another theory attributes the association between
trauma and risk-taking behaviors as a way to alter and buffer one’s emotional experience
in the face of trauma. The authors’ of the above study hypothesized that higher levels of
PTSD symptomology would be positively correlated with higher levels of risky behaviors
(Strom et al., 2012).
The results of the study found that OEF/OIF veterans scored significantly higher
on the PCL (a test measuring PTSD symptoms and severity) when compared to veterans
from other wars. Furthermore, OEF/OIF veterans scored higher on scales measuring risky
sexual behavior, and aggressive behaviors, reaffirming the association between PTSD
severity and risk-taking behaviors (Stromet et al., 2012). In addition, participants who
scored higher than 50 on the PCL showed higher frequencies of risk-taking behaviors.
Specifically, higher rates of engaging in “thrill-seeking behaviors,” aggressive behaviors,
and possession of weapons were statistically associated with PTSD severity. These risktaking behaviors are also apparent in the context of substance abuse. Accordingly, the
study showed high PCL scores in association with increased levels of smoking, alcohol
abuse, and drinking and driving (Strom et al., 2012). Similarly, veterans exposed to
trauma are four times greater than the general population to experience suicidal ideations
35
as a coping mechanism. Unfortunately, little research has been done on risk-taking
behaviors among veterans in association with severity of PTSD. However, it is highly
needed due to the negative coping styles seen that weigh heavily on the veterans
themselves, their families, and communities. For this reason, the researchers will use risktaking behaviors as a variable in the current study.
Suicidal Ideations and Attempts
As discussed above, suicidal tendencies are considered risk-taking behaviors that
have been associated with PTSD. Extensive research has shown a definite correlation
between the risk of suicide and a PTSD diagnosis, with research showing that PTSD is
associated with higher rates of suicidal ideations (Pietrzak, Goldstein, Malley, Rivers,
Johnson, & Southwick, 2010). However, little research exists which examines specific
risk factors for suicidal ideations in the context of PTSD. This is significant because
factors such as PTSD increase veterans’ vulnerability to suicide (Pietrzak et al., 2010).
More specifically, suicidal ideations among veterans are also associated with increased
exposure to combat, difficulties obtaining care, decreased social support, and stigma
(Pietrzak et al., 2010).
Data from the National Violent Death Reporting System examined the high rates
of death by suicide of veterans as a means of coping with war related trauma. In
comparison to civilians, male veterans are two times more likely and female veterans are
three times more likely to commit suicide (Swofford, 2012). One study examined
suicidality in treatment seeking OEF/OIF veterans in relation to coping strategies,
resilience, and social support (Pietrzak, Russo, Ling, & Southwick, 2011). A study by
36
Jakupcak et al., (as cited in Pietrzak et al., 2011) found that while increased social
support is a protective factor against suicidality among most veterans, social support did
not have a protective effect among veterans with PTSD. In addition, “maladaptive
cognitive coping strategies” and “experiential avoidance” have been associated with
increased suicidality in both number of attempts, ideations, and overall psychological
pathology (Pietrzak et al., 2011, p. 721).
Numerous studies have corroborated that the emotionally numbing characteristics
of both PTSD and depression are associated with increased risk for suicide among
OIF/OEF veterans (Pietrzak et al., 2011). A high percentage (48.5%) of the sample
surveyed in this study screened positive for PTSD. Furthermore, individuals who
reported current suicidal ideations were more likely to screen positive for PTSD,
depression, and service related physical pain or discomfort. The study also found that
suicide prone individuals had higher combat exposure rates, utilized cognitive avoidance
strategies to cope, and lacked social support when compared to non-suicide
contemplators (Pietrzak et al., 2011). Overall, the sample studied showed a high rate of
suicidal thoughts, with 1 in 5 veterans surveyed reporting suicidal cognitions at the time
of the study. These high numbers may be attributed to the fact that the sample was
treatment seeking and therefore more likely to be experiencing psychological pathology.
However, the sample was recruited from both mental health clinics and primary care
clinics, demonstrating the importance of suicide screening at all levels of veteran care
(Pietrzak et al., 2011). Another notable result of the study is that psychological resilience
and the ability of a veteran to accept change were negatively correlated with suicidal
37
ideations. These findings further underscore the importance of the role which coping
styles play in psychological impairment and social readjustment post-trauma (Pietrzak et
al., 2011). Due to the increasing rates and prevalence of suicide as a coping method, this
variable will be further examined in the current study.
Spiritual Well-Being and Religious Coping
A significant amount of research exists on the association of religious coping
styles and mental health in individuals without PTSD, but little has been done on the
relationship between religious coping and mental health issues in the context of PTSD
(Witvliet, Phipps, Feldman, & Beckham, 2004). Veterans with PTSD utilize both positive
and negative religious coping styles that have a strong association to the severity of their
mental health issues (Witvliet et al., 2004). Veterans that employ positive religious
coping responses report less distress in comparison to veterans that use negative religious
coping styles who show more severe mental and physical health problems (Witvliet et al.,
2004). This particular study defines positive religious coping as “seeking spiritual
support, collaboration with God in solving the problem, and positive religious appraisals
of the problem” (Witvliet et al., 2004, p. 271). Whereas, negative religious coping is
measured by variables such as “interpersonal religious discontent, questioning God’s
powers, and appraisal of the problem as God’s Punishment” (Witvliet et al., 2004, p.
271).This study examined how negative religious coping is associated with higher levels
of anxiety, depression, and mental health problems in veterans in contrast to positive
religious coping (Witvliet et al., 2004). The authors found that difficulty forgiving one’s
self and negative religious coping were positively associated with high levels of anxiety
38
and depression (Witvliet et al., 2004). Furthermore, positive religious coping was
associated with less severe PTSD symptoms in comparison to individuals who employed
negative religious coping styles (Witvliet et al., 2004). This reveals the importance of
examining and evaluating variables of positive and negative religious coping in the
treatment of veterans.
Another study had similar findings when the authors examined the association
between suicidality, levels of cortisol, and spiritual well-being (Mihaljevic,Vucsan-Cusa,
Marcinko, Koic, Kusevic, & Jakovljevic, 2011). Veterans with PTSD tend to have high
levels of cortisol, and due to cortisol’s relationship with stress, cortisol is often used as a
predictor of suicide (Mihaljevic et al., 2011). The research found that high cortisol levels
were correlated with a higher suicide risk among veterans, and that high levels of
spiritual well-being were correlated with low levels of cortisol (Mihaljevic et al., 2011).
This infers that higher levels of spiritual well-being are associated with lower suicide risk
among veterans (Mihaljevic et al., 2011). In this study, spiritual well-being was defined
as a “sense of purpose in life and satisfaction in life” (Mihaljevic et al., 2011, p. 469).
High levels of spiritual well-being in this case served as a protective factor among
veterans diagnosed with PTSD (Mihaljevic et al., 2011). The study found that spiritual
well-being was a “mediating factor” for the alleviation of PTSD symptoms often found in
suicide cases among veterans (Mihaljevic et al., 2011, p. 470). This study agreed with
prior research showing an association between low spiritual well-being and higher
suicide risk (Mihaljevic et al., 2011). Previous research shows that the inclusion of
spiritually based interventions in PTSD treatment is important in reducing mental health
39
issues and suicidal behavior among the veteran population (Mihaljevic et al., 2011). This
finding emphasizes the importance of incorporating spiritual well-being into the
treatment of PTSD in order to curb suicide rates and negative coping styles among
veterans. In addition, the above findings highlight the significance of including this factor
in the current study.
40
Chapter 3
METHODS
The purpose of this study is to explore different coping styles which veterans
diagnosed with PTSD utilize in response to trauma. Insight into how different coping
styles affect social functioning and PTSD symptom severity allows clinicians to
effectively treat this population. This understanding may lead to more effecient
interventions targeting the population’s specific needs. The researchers hope to highlight
positive coping styles that are often over looked by practitioners who tend to focus on the
more common negative symptoms of trauma. The researchers hope this knowledge will
prompt practitioners to incorporate psycho-educational materials and interventions
targeting positive coping methods into their practice.
Study Objectives
This study uses quantitative methods of analysis to determine statistical outcomes
of the authors’ research questions. Participants were recruited using a non-randomized,
snowball sampling study design. The researchers hypothesize that positive coping styles
such as social support, religious coping, and Post-Traumatic Growth will result in a
higher level of social functioning and less severe PTSD symptoms. In comparison, the
researchers propose that negative coping styles such as substance abuse, risk-taking
behaviors, and behavioral withdrawal, will be related to an increase in PTSD symptom
severity and a lower level of social functioning. The following pages outline in greater
detail the design of the study, methods of sample recruitment, and data analysis methods.
41
Study Design
The study used quantitative methods and was both exploratory and descriptive in
nature. The survey consisted of 34 total questions including demographic information,
questions referring to coping styles, PTSD symptom severity, and social functioning. The
researchers examined 11 established coping styles from various studies of PTSD in the
veteran population. The coping styles include; anger and dissociation, behavioral
avoidance (withdrawal), cognitive avoidance, substance abuse, suicidal ideations and/or
attempts, risk-taking behaviors, PTG (Post-Traumatic Growth), positive religious/
spiritual coping, positive behavioral approach strategies, self-narratives, social support,
and an “other” category for coping styles not listed above . The relationship between
variables was measured by comparing each coping style to both levels of social
functioning and PTSD symptom severity. Statistical analysis of these variables
determined whether any statistically significant associations exist. The independent
variable in the study design is the coping style, while the dependent variables are the
levels of social functioning and PTSD symptom severity.
Sampling Procedures
Participants included clinicians who have provided mental health services to
PTSD diagnosed U.S. veterans within the past ten years. The population sample included
participants possessing the follow qualifications; MSW/LCSW, MFT/LMFT, PsyD, and
Ph.D. The researchers obtained a total of 33 responses from mental health professionals
which comprised the n of this study (population sample size). The sample was recruited
from a list serve of members of the California Clinical Society for Social Work; a
42
massive e-blast (email) was sent to members requesting their voluntary participation. In
addition, these members were asked to forward the survey to any qualified colleagues
through a utilization of snowball sampling techniques. Additional participants were
recruited from the EMDR International Association’s list of members, and a list of
therapy providers in California connected to TRICARE insurance (a military and veteran
health insurance company).
Data Collection Procedures
Researchers collected data through Survey Monkey, an online surveying tool. The
survey included mainly closed ended questions with the exception of a few open-ended
responses in regards to demographic information. The data was analyzed using statistical
analysis methods consistent for nominal data sets. The researchers coded the data into
numerical form by assigning a numerical value to each descriptive response in the survey.
SAS [1] was then used to conduct numerical data analysis. In addition to answering the
main research questions, the researchers performed analysis focusing on participant
demographics. Demographic information studied included the following; the clinicians’
gender, education level, years of experience working with veterans, military status,
number of veterans treated in total, and current caseload percentage of veterans. This step
of analysis was important because it provided a summary of the sample characteristics,
which assisted with identifying possible bias and differences in opinion based on varying
demographic information. Additional statistical analysis was conducted in relation to
each coping style and their statistical relationship to levels of social functioning and
PTSD symptom severity. In addition, the researchers conducted a comparative analysis of
43
the outcome measures (social functioning and symptom severity) of all the combined
negative coping styles and combined positive coping styles.
Instruments
PTSD symptom severity and social functioning were measured by modified scales
of the PTSD Checklist-Military Version and the Social Functioning Questionnaire. The
symptom severity scale is comprised of 17 DSM-IV symptom criteria for a diagnosis of
PTSD. Measurements of social functioning include factors such as; ability to complete
tasks at home, employment, intimacy in relationships, sexual functioning, finances,
relationships with family and relatives, relationship with friends, quality of social
interactions, isolation, housing, legal problems, substance abuse, goal setting, anhedonia,
and emotional regulation. The measurements of the dependent variables were based on
professionals’ perspectives of social functioning and symptom severity. The researchers
addressed issues of reliability and validity by creating survey questions that were clear,
concise and free of bias, and increased reliability and validity by defining each variable
for the participants.
Data Analysis
The study included a large number of variables as outlined below. For each of the
11 coping styles there were 17 variables measuring symptom severity and 16 variables
measuring social functioning. Data entry was accomplished by numerically coding
participants’ descriptive responses into numerical values ranging from 1-5. PTSD
symptom severity questions were numerical coded as follows; 1 as not affected, 2 as
mildly affected, 3 as moderately affected, 4 as strongly affected, and 5 as extremely
44
affected. Social functioning numerical values included; 1 as no problems at all, 2 as
occasional problems, 3 as moderate problems, and 4 as severe problems. Demographic
information was also coded into numerical values to allow for nuanced statistical analysis
to be performed.
In order to perform statistical analysis of each dependent variable (symptom
severity and social functioning), repeated measures analysis were used. This method was
employed to ensure dependency between the different observations of each participant.
This is important to consider because each participant answered more than one question
in the survey. For each research question, a linear mixed effect model with demographics
as the covariates was used to determine any differences that existed between positive and
negative coping types. All variables in the study were assumed to be fixed effects,
meaning that the researchers did not account for other variables or coping styles that
could potentially affect social functioning and symptom severity outcomes. To address
within-subject variation, compound symmetry (CS) covariance matrices were used. This
allows the researchers’ to assume that the covariance (which is a measure of the degree in
which two variables or observations correspond to each other) within one participant is a
constant.
The F test was used to determine statistical significance between variables. The F
test works under the assumption that the study sample is normally distributed.
Furthermore, the employment of an F test allowed the researchers’ to either accept or
reject the null hypothesis; determining whether a relationship existed between the
variables being studied. In determining whether variables have a statistically significant
45
relationship the researchers examined the p-value of variables, with a p-value of less than
0.05 indicating statistical significance. Lastly, estimated marginal means and standard
error (SE) for each variable were examined. The researchers’ employed the use of an
estimated marginal mean due to the varying number of responses for each question.
Estimated marginal means also allow for other variables such as demographic
information to be accounted for during statistical analysis. In order to satisfy the
requirements of normal distribution which the F test and linear mixed effect model
require, the researchers’ tested the sample to determine its’ distribution pattern. In order
to test the distribution the factors such as skewness, kurtosis, and the KolmorgorovSmirnov test of normality were used.
Protection of Human Subjects
The protocol for the Protection of Human subjects was submitted and approved on
October 24, 2012 by the Committee for the Protection of Human subjects as exempt from
risk. The human subject’s approval number is 12-13-023. The research project was
identified as no risk, because the participants’ discomfort level is consistent to what they
may encounter on a daily basis in their professional and personal lives. This is attributed
to the survey design and the fact that the veteran population was not directly surveyed.
Rather, responses were collected from professionals working with the population, who
encounter the type of information asked in the survey regularly in their professional lives.
The researchers can safely assume professionals in the sample are comfortable with the
survey content, as it is within their daily routine to encounter these types of questions and
subject matter. In addition, the survey is exempt from risk due to the participants' being
46
voluntary and having the right to not complete, skip questions, or end the survey at any
point in time.
Participation is voluntary, and the participants’ privacy rights are protected
through measures embedded in Survey Monkey's design. Survey Monkey utilizes
“privacy practices” in order to protect the participant’s responses. These practices are
disclosed on the researchers’ informed consent, which is included on the introduction
page of the survey. Survey Monkey’s “Privacy Policy and Security Statement” explains
the practices by which participants' information is protected which includes; informed
consent, secure transmission, database security, server security, and masked IP addresses.
Informed consent was electronically obtained from participants prior to the start of the
survey through survey monkey. A written consent was not acquired, because the survey
was collected using an online medium. However, participants gave their consent by
clicking “I accept” and beginning the survey. Researchers carefully coded the data to
protect personal information and confidentiality.
The information gathered was protected by limiting data access to include only
the researchers and Dale Russell, faculty advisor to the project. Each participant was
assigned an identification number when conducting data analysis, keeping their names
confidential and only known to the researchers. Furthermore, the data was stored and
analyzed on a personal password protected computer. The original data with participants’
names was destroyed in April 2013 in order to protect participants’ privacy. The
researchers secured voluntary participation of the population sample by providing a $5
Starbucks gift card incentive for participation in the study. Furthermore, the researchers
47
educated the sample on the study’s potential implications for best practices in working
with veterans. This data holds clinical significant due to the influx of returning combat
veterans from Iraq and Afghanistan with symptoms of combat stress, PTSD, and war
related trauma.
48
Chapter 4
STUDY FINDINGS AND DISCUSSIONS
The findings of this study are based on professionals’ perspectives who have
worked with veterans diagnosed with PTSD in the last ten years. The main objective of
the study was to determine if there was a difference between positive and negative coping
styles as measured by symptom severity and social functioning. The researchers’
hypothesized that positive coping styles would have a lower symptom severity and
higher social functioning, and negative coping styles would have a higher symptom
severity and overall lower social functioning. Positive coping styles were categorized to
include the following coping styles; PTG, positive behavioral approaches, self-narratives,
religious/ spiritual, and social support. Negative coping styles included the following;
anger and dissociation, cognitive avoidance, substance use, risk-taking behaviors,
suicidal ideations, and behavioral avoidance. Specific findings related to demographic
information and the researchers’ hypothesis are discussed in detail below.
Overall Findings
The current study included a total of 33 participants who possessed varying
demographic characteristics. Demographic categories included in the current study are
gender, education level, years of experience working with veterans with PTSD, US
military status, total number of veterans treated, and the percent of veteran clients on
their current caseload. Table 1 shows the demographic information of the 33 participants
through the use of a one-way frequency of percentages. One aspect of demographic
information that is important to note is the distribution of gender (women, 69.7%; men,
49
30.3%). In addition, a large percentage of the sample came from one professional
modality (MSW/LCSW, 63.64%). Furthermore, the study included professionals who
were experienced in treating the veteran population as 65.38 percent had treated over 50
veterans. Lastly, of the professionals surveyed, 65.22 percent had a caseload that
included 100 percent veterans, demonstrating the validity of their perspectives.
Table 1
One-way frequency table of demographics
Demographics
Gender
Category
Male
Female
Frequency
10
23
Percentage
30.30
69.70
Education level
MSW/LCSW
MFT/LMFT
Ph.D/Psy.D
MD
Other
21
4
4
1
3
63.64
12.12
12.12
3.03
9.09
0-5
5-10
10-15
15+
15
6
6
6
45.45
18.18
18.18
18.18
No
Yes
Active duty
Veteran
26
2
2
3
78.79
6.06
6.06
9.09
Total Veterans treated
50 or less
Over 50
Missing (no response)
9
17
7
34.62
65.38
Veteran percent
25%
50%
75%
100%
Missing (no response)
5
1
2
15
10
21.74
4.35
8.70
65.22
Years of experience working with veterans with
PTSD
US military status
Overall, there were two main research questions being addressed in this study.
The first being, was there a difference between positive and negative coping styles as
measured by symptom severity? The second being, was there a difference between
50
positive and negative coping styles as measured social functioning. When testing the
hypothesis it is important to either accept or reject the null hypothesis based on the
findings. The null hypothesis was rejected in this study, due to the fact that there was a
relationship between the dependent and independent variables. More specifically, the
authors found a relationship exists between positive and negative coping styles and
symptom severity, as well as positive and negative coping styles and social functioning.
Specific Findings
Specific findings are discussed below in regards to the first research question
which was, is there a difference between positive and negative coping styles as measured
by symptom severity? Statistically significant differences were measured by mean
composite scores of symptom severity between negative and positive coping styles.
There was a statistically significant difference between positive and negative coping
styles as measured by symptom severity (F(1, 17) = 157.40, p < 0.0001). The estimated
marginal mean for the composite score of symptom severity for negative coping was
64.92 (SE = 2.14). While the estimated marginal mean for the composite score for
positive coping was 44.96 (SE = 2.38). Table 2 presents descriptive statistics of the
overall mean scores for symptom severity for each individual coping style studied.
51
Table 2
Descriptive statistics of symptom severity, by coping type and coping style
Coping
type
Negative
Positive
Coping style
N
Mean
SD
Minimum
Maximum
Overall
Anger and
Dissociation
Behavioral
Avoidance
Cognitive
Avoidance
Risk Taking
Behaviors
Substance Use
Suicidal Ideations
130
28
66.35
64.07
14.24
9.88
17
42
85
79
22
66.68
11.94
45
85
19
62.11
16.17
27
85
18
68.28
15.93
22
85
23
20
67.52
70.15
13.75
18.46
34
17
85
85
Overall
Positive
Behavioral
Approaches
Narrative
PTG
Religious/Spiritual
Social Support
59
14
43.25
44.50
11.64
13.05
22
26
71
68
10
9
9
17
41.10
39.89
43.33
45.24
9.96
11.49
15.94
9.42
28
22
23
30
59
56
71
67
Note. N = sample size SD = standard deviation
Figure 1 demonstrates the differences in the means between these two coping types in
relation to symptom severity scores.
52
Figure 1: Box plot of the composite scores of symptom severity by coping type
Specific findings regarding the second research question which was, is there a
difference between positive and negative coping styles as measured by social functioning
are discussed below. The researchers’ found statistically significant differences on the
mean composite scores of social functioning between negative and positive coping styles
(F(1, 24) = 267.18, p < 0.0001). More specifically, the estimated marginal mean for the
composite score of social functioning for negative coping styles was 50.42 (SE = 1.44),
compared to 33.75 (SE = 1.63) for positive coping styles. Table 3 presents the descriptive
statistics of the mean scores for each coping style in relationship to social functioning
outcomes.
53
Table 3
Estimated marginal means of coping styles, symptom severity
Coping type
Coping style
Negative
Anger and Dissociation
Behavioral Avoidance
Cognitive Avoidance
Risk Taking Behaviors
Substance Use
Suicidal Ideations
Positive
Positive Behavioral
Approaches
Narrative
PTG
Religious/Spiritual
Social Support
Estimated marginal
means
63.18
64.65
60.57
65.87
66.28
68.99
Standard error
44.57
3.15
44.18
45.11
45.98
44.94
3.55
3.74
3.69
2.97
2.67
2.80
2.92
2.91
2.73
2.82
Figure 2 demonstrates the differences in the means between positive and negative coping
styles in relation to social functioning scores.
Figure 2: Box plot of the composite scores of social functioning by coping type
54
Statistically Significant Demographic Differences
There were various statistically significant differences based on the demographic
categories in the study. For example, there was a statistically significant difference on the
mean composite scores of symptom severity between male and female perspectives (F(1,
26) = 5.50, p = 0.0269). The estimated marginal mean for the composite score of
symptom severity (for both positive and negative coping) for male participants was 50.00
(SE= 3.39), in comparison to female participants which was 60.88 (SE = 2.52).
Furthermore there were statistically significant differences in perspective related to
symptom severity based on the educational levels of participants (F(1, 26) = 12.86, p =
0.0014). Due to the small number of subjects this category was collapsed into two
categories, MSW/LCSW and “other” which included MFT/LMFT, Ph.D, Psy.D, MD,
and other. The estimated marginal mean for the composite score of symptom severity for
the MSW/LCSW category was 61.81 (SE = 2.53), in comparison to 48.07 (SE = 3.15) for
the “other” category. A statistically significant difference on the mean composite scores
of symptom severity between the two levels of US military status, “no” and “yes” was
also found (F(1, 26) = 8.68, p = 0.0067). The estimated marginal mean for the composite
score of symptom severity for active duty or veteran participants was 61.38 (SE= 3.56),
compared to 48.51 (SE = 2.42) for non-veterans in the sample. There were no statistically
significant differences in estimated marginal mean scores based on demographic
characteristics of the sample for social functioning outcomes.
Demographic findings of no statistical significance. There was no statistically
significant difference on the mean composite scores of symptom severity between
55
varying levels of experience working with veterans (F(1, 26) = 0.74, p = 0.3971).
Categories were collapsed into two categories defined as follows; 0-5 years experience
and 5 or more years. The estimated marginal mean for the composite score of symptom
severity for people with 0-5 years of experience was 53.29 (SE= 3.30), compared to 56.59
(SE= 3.32) for professionals with 5 or more years of experience. The following
demographic information shows no statistically significant differences on the mean
composite scores for social functioning outcomes.
There was no statistically significant difference on the mean composite scores of
social functioning between male and female participants in the study (F(1, 24) = 1.60, p
= 0.2177). Specifically, the estimated marginal mean for the composite score for male
participants was 40.24 (SE = 2.36), compared to 43.29 (SE = 1.69) for females. In
addition, there was no statistically significant difference on the mean composite scores of
social functioning between the two education levels (F(1, 24) = 1.89, p = 0.1824). The
estimated marginal mean for the composite score for the “MSW/LCSW” category was
44.00 (SE = 1.69), in comparison to 40.17 (SE = 2.29) for the “other” category. In
addition, no statistically significant differences were found on the mean composite scores
of social functioning between the two categories related to years of experience working
with veterans with PTSD (F(1, 24) = 0.59, p = 0.4502). The estimated marginal mean for
the composite score of participants with 0-5 years of experience was 41.00 (SE = 2.38),
while the estimated marginal mean for the composite score for clinicians with 5 or more
years of experience was 43.16 (SE = 1.58). Lastly, there were no statistically significant
differences on the mean composite scores of social functioning in regards to the US
56
military status of participants (F(1, 24) = 0.89, p = 0.3545). Accordingly, the estimated
marginal mean for the composite score for participants who were active duty or veterans
was 40.71 (SE = 1.66), compared to 43.45 (SE = 2.38) for non-veterans.
Statistical Relationships between Coping Styles
Further analysis was done to determine whether a relationship existed between
varying coping styles within their respective categorization of either positive or negative
coping. The analysis is discussed in detail below.
Relationships measured by symptom severity. There were no statistically
significant differences between the mean composite scores for symptom severity among
individual coping styles within each positive or negative categorization (F(9, 131) = 1.11,
p = 0.3609). To further elaborate, when measuring symptom severity scores, there were
no statistically significant differences among negative coping styles (anger and
dissociation, behavioral avoidance, cognitive avoidance, risk taking behaviors, substance
use, and suicidal ideations) within that categorization. Similarly, this same finding was
duplicated among positive coping types. Table 4 shows the estimated marginal means of
each coping styles as measured by symptom severity outcomes.
57
Table 4
Descriptive statistics of social functioning, by coping type and coping style
Coping
type
Negative
Positive
Coping style
N
Mean
SD
Minimum
Maximum
Overall
Anger and
Dissociation
Behavioral
Avoidance
Cognitive
Avoidance
Risk Taking
Behaviors
Substance Use
Suicidal Ideations
121
26
51.68
51.15
8.53
6.99
32
32
64
64
20
50.55
8.31
32
64
17
43.88
8.49
34
64
16
54.88
8.51
35
64
23
19
53.78
55.32
8.29
6.90
37
40
64
64
Overall
Positive Behavioral
Approaches
Narrative
PTG
Religious/Spiritual
Social Support
51
12
33.51
33.00
5.49
3.22
23
27
61
38
9
7
7
16
32.33
34.00
39.14
31.88
3.35
2.24
11.67
3.42
27
31
31
23
37
38
61
36
Notes: N= sample size. SD = standard deviation.
Figure 3 presents a box plot of the composite scores of symptom severity as measured by
each coping style. This figure visually demonstrates the information presented above
showing differences in mean composite scores measuring symptom severity for each
individual coping style.
58
Figure 3: Box plot of the composite scores of symptom severity by coping style. Label for the horizontal
axis is as follows: 1=anger and dissociation, 2=behavioral avoidance, 3=cognitive avoidance, 4=risk-taking
behaviors, 5=substance use, 6=suicidal ideations, 7=positive behavioral approaches, 8=self-narrative,
9=PTG, 10=religious/spiritual, 11=social support.
Relationships measured by social functioning. Several statistically significant
relationships were found within positive and negative categories between coping styles
for social functioning outcomes (F(9, 117) = 7.16, p < 0.0001). Among the negative
coping category, the following significant associations were found. There was a
statistically significant difference found between the estimated marginal mean for the
composite scores of anger and dissociation and cognitive avoidance (p < 0.0001). A
statistically significant difference was found between the estimated marginal mean for the
composite scores of behavioral avoidance and cognitive avoidance (p = 0.0070). In
addition, there was a statistically significant difference found between the estimated
marginal mean for the composite scores of cognitive avoidance and risk-taking behaviors
59
(p < 0.0001). Lastly, a statistically significant difference was found between the estimated
marginal mean for the composite scores of cognitive avoidance and substance use (p <
0.0001). Table 5 shows the estimated marginal mean scores of each coping styles as
measured by social functioning outcomes.
Table 5
Estimated marginal means of coping styles, social functioning
Coping type
Coping style
Negative
Anger and Dissociation
Behavioral Avoidance
Cognitive Avoidance
Risk Taking Behaviors
Substance Use
Suicidal Ideations
Positive
Positive Behavioral
Approaches
Narrative
PTG
Religious/Spiritual
Social Support
Estimated marginal
means
50.28
49.64
42.73
52.74
53.12
53.98
Standard error
1.74
1.82
1.90
1.92
1.77
1.82
32.33
2.08
32.79
32.81
39.79
31.01
2.30
2.54
2.50
1.92
Figure 4 demonstrates the mean scores of social functioning as separated by each coping
type as discussed above.
60
Figure 4: Box plot of the composite scores of social functioning by coping style. Label for the horizontal
axis is as follows: 1=anger and dissociation, 2=behavioral avoidance, 3=cognitive avoidance, 4=risk-taking
behaviors, 5=substance use, 6=suicidal ideations, 7=positive behavioral approaches, 8=self-narrative,
9=PTG, 10=religious/spiritual, 11=social support.
Normality Assumption
Due to the fact that the data was analyzed using measures which assume a normal
distribution of the sample; in order to demonstrate validity of the results the authors’ must
ensure the sample was in fact normally distributed. Accordingly, the sample was tested
for normal distribution on both symptom severity and social functioning outcomes. Both
were found to have a normal distribution as discussed below. The skewness and kurtosis
of the residuals from the fitted model for symptom severity were -0.61 and 0.48,
respectively. Furthermore, the Kolmogorov-Smirnov test did not reject the null
hypothesis that the residuals were normally distributed (p = 0.0596). The QQ plot
61
(Figure 5) shows the residuals for the responses of symptom severity questions and
implies that they follow a normal distribution.
Figure 5: QQ plot for symptom severity
Similarly, normal distribution for responses to the social functioning questions
were also established. In this case, the skewness and kurtosis of the residuals from the
fitted model were -0.071 and 0.63. Furthermore, the Kolmogorov-Smirnov test did not
reject the null hypothesis that the residuals were from a normal distribution (p > 0.1500).
Lastly, the QQ plot (Figure 6) suggests that the residuals for the responses of social
functioning questions follow a normal distribution. In conclusion, the authors can
conclude that the normality assumption was satisfied for both symptom severity and
social functioning. Therefore, the fitted model, which was used to perform data analysis,
was adequate and valid.
62
Figure 6: QQ plot for social functioning
Interpretations to the Findings
The overall findings support the researchers’ hypothesis. The mean composite
scores for the symptom severity measure were higher for negative coping styles and
lower for positive coping styles. This finding suggests there is a relationship between
veterans who utilize negative coping in response to trauma and high levels of PTSD
symptom severity. Accordingly, there is an association between veterans who utilize
positive coping styles in response to trauma, and lower levels of symptom severity. These
findings suggest that differences in coping styles may affect the severity of PTSD
symptoms in veterans.
In addition, the mean composite scores for the social functioning measure were
higher for negative coping styles and lower for positive coping styles. This finding
suggests an association exists between veterans who use negative coping styles and
exhibit lower levels of social functioning (higher social functioning “problems” score).
63
Similarly, a relationship was found between veterans who utilize positive coping styles
and exhibit higher levels of social functioning (lower social functioning “problems”
score). This finding suggests that positive coping styles may influence veterans in having
higher social functioning levels, and less social problems upon societal reintegration.
Furthermore, differences in responses were found based on the demographic
characteristics of participants. Interestingly, demographic information affected
professionals’ perspectives on symptom severity but not for social functioning measures.
For example, women professionals in the sample tended to rate symptom severity for all
the coping types as more severe than male participants. Differences in perspective were
also found based on participants’ level of education. Those with a MSW/LCSW
background were more likely to highly rate PTSD symptom severity when compared to
other educational backgrounds. Furthermore, whether or not participants were currently
in the military or were veterans affected their perspective on symptom severity levels.
Those who were active duty or veterans rated symptom severity as more severe than
those participants who did not have a military background.
Summary
In conclusion, the above data suggests that differences in the way that
professionals’ perceive that veteran clients cope with PTSD contribute to varying levels
of symptom severity and social functioning outcomes. In addition, demographic
characteristics of the professionals play a role in their perception regarding levels of
PTSD symptom severity among veteran clients. Furthermore, the findings suggest a
statistically significant relationship between negative coping styles, (anger and
64
dissociation, behavioral avoidance, cognitive avoidance, risk taking behaviors, substance
use, and suicidal ideations) higher levels of symptom severity, and lower levels of social
functioning. On the other hand, a statistically significant association between positive
coping styles, (positive behavioral approaches, self-narrative, PTG, religious/ spiritual,
and social support) lower levels of PTSD symptom severity, and higher levels of social
functioning was found.
65
Chapter 5
CONCLUSION, SUMMARY, AND RECOMMENDATIONS
Summary of Study
The current exploratory study aimed to examine differences in coping styles, which
veterans use to manage trauma in the context of PTSD. In examining varying ways of
managing trauma within this population, the authors’ intention was to suggest more
effective ways in treating veterans with a PTSD diagnosis. An additional purpose of this
study was to promote an awareness of strengths based approaches to treatment such as
the recovery model. This secondary purpose was addressed by emphasizing the positive
implications of adaptive ways of coping with trauma, which tend to be overshadowed by
more traditional approaches to mental health treatment. Data collection consisted of 33
on-line surveys collected from mental health clinicians who work with this population.
The findings of the study were summarized in the previous chapter. The current chapter
will discuss these findings and their implications for the treatment of veterans with
PTSD.
Implications for Social Work
A major implication stemming from the results of the study suggest that a larger
emphasis be placed on preventative treatment, outreach, and psycho-education regarding
positive coping methods in the treatment and management of military trauma. The social
work field can incorporate these recommendations by using a recovery-oriented
philosophy in the treatment and engagement of veterans with a PTSD diagnosis. Current
mental health treatment of veterans focuses on symptom management, is reactive in
66
nature, and uses a medical model approach (Sayer, Noorbaloochi, Frazier, Carlson,
Gravley, & Murdoch, 2010). In comparison, the recovery model is an evidence based
treatment, movement, and philosophy; focusing on strengths over deficits, stigma
reduction, and consumer involvement in treatment (Davidson, Tondora, Staeheli &
Lawless, 2009).
The recovery model promotes consumer empowerment and outlines several
guiding principles of practice to ensure that the philosophy is adhered to in mental health
settings. These principles, which are outlined below, could easily translate to treatment
practices and services for the veteran population; especially within the VA system, which
leans towards a medical model approach. The utilization of the recovery model in the
mental health treatment of veterans supports the findings of this study, which suggest
better outcomes in areas of social functioning and PTSD symptom severity through the
use of positive coping styles. Davidson et al., (2009) define recovery as a process of
addressing and treating symptoms of mental illness while simultaneously focusing on a
person’s strengths, interests, and humanity beyond the label of their psychiatric disorder;
something that is not currently done well within the VA system.
For example, veteran consumers in one study felt that VA services tend to focus
heavily on symptom reduction while largely ignoring community reintegration issues; a
topic that veterans with PTSD felt was more important and relevant to their treatment
(Sayer et al., 2010). On the contrary, recovery oriented care places the patient in the
position of expert when determining their treatment and goals. The consumers of services
identify goals, “interests and abilities,” which will drive their path of recovery and the
67
services that they receive (Davidson et al., 2009, p.22). The implications from the above
study suggest that the VA could benefit from incorporating principals of the recovery
model which value consumer preferences, promote empowerment, and stigma reduction.
The recovery philosophy values fostering a sense of belonging within one’s
community, defining oneself as a person separate from the diagnosed illness, and
reconstructing one’s life in a way which is fitting for that individual (Davidson et al.,
2009). The National Consensus Statement on Mental Health Recovery (2006) recruited a
panel of over 110 individuals who collaboratively identified ten aspects of recovery as
follows; “hope, self-direction, individualized and person centered, empowerment,
holistic, non-linear, strengths based, peer support, respect, and responsibility” focused
treatment. The review of literature discussed concepts specific to the veteran community
that closely coincide with the main tenants of the recovery model.
The literature review discusses several positive coping styles such as social
support, community reintegration, and peer-based programs; all of which are associated
with successful outcomes including decreased PTSD symptom severity, and higher levels
of social functioning (Benetato, 2011; Pietrzak et al., 2011; Resnick, Bradford et al.,
2012). Existing literature, findings of the current study, and the effectiveness of the
recovery model suggest successful treatment outcomes through recovery oriented
approaches. The above evidence supports the authors’ proposal for the utilization of this
approach in the treatment of trauma exposed veterans. The implication for social work
practice is clear; promoting positive coping techniques through the employment of
recovery model principals would contribute to better outcomes for veterans with PTSD.
68
In addition to the components discussed above, the recovery model strongly
advocates for consumer empowerment through stigma reduction in the context of mental
health treatment. In military culture, a large stigma exists related to mental health
diagnosis and treatment (Demers, 2011). As a result, many active duty and veteran
military members encounter stigma related barriers in getting needed treatment when
facing mental health challenges. Rather than reaching out to mental health professionals
for support, this may contribute to the use of maladaptive coping styles in trauma
exposed veterans such as substance use or social withdrawal (Demers, 2011).
Accordingly, the recovery model’s focus on stigma reduction is applicable to the
treatment of Veterans. A stigma reduction campaign within military culture may prompt
a decrease in mental health treatment barriers and an increase in positive treatment
outcomes for veterans.
Gene Deegan (2003) a self-identified consumer, researcher, and doctor, promotes
strengths based ideologies and proposes that recovery models are successful in positive
mental health treatment outcomes. Recovery oriented values of promoting hope,
involvement in the community, and becoming an empowered citizen are concepts
discussed in the review of the literature that were similarly associated with effective
treatment outcomes among veterans. Peer based support, shared experiences that promote
a feeling of understanding, and involvement in the community help buffer the effects of
trauma (Benetato, 2011). Similarly, the findings of the current study suggest that the use
of social support, self-narratives, and positive religious coping as ways of managing
trauma are associated with successful outcomes. The above components not only
69
coincide with the recovery approach, but they have been identified as important aspects
of treatment by veterans themselves. Accordingly, consumers of VA services expressed
similar opinions focusing on the need for community reintegration programs and the gaps
in current policies in addressing this need (Sayer et al., 2010).
The medical model of treatment tends to be deficit based with a large emphasis on
symptom management. On the other hand, the recovery model is more aligned with the
strengths based philosophy of treatment. Furthermore, a strengths based approach closely
relates to many of the positive coping styles identified in the current study, which were
related to better treatment outcomes. In addition, encouraging consumers to draw upon
their personal strengths to work towards self-identified goals is an important part of both
recovery and strengths based paradigms (Deegan, 2003). The authors’ suggest that the
VA shift its focus to be more in line with these ideologies. In summary, the recovery
model teaches people that they are not bound or defined by their disorders, and strives to
foster meaningful roles for individuals living with psychiatric illnesses. For the veteran
community, this paradigm creates an important opportunity for individuals to coconstruct their own self-narrative outside of what society expects from someone who has
a label such as PTSD.
Recommendations
In order to produce more accurate and detailed outcomes in future studies, it
would be beneficial to collect data from the veteran population directly. This would allow
for important differences in outcomes based on varying demographic information to be
included in future studies. This would allow for less bias in the study because the
70
information gathered would be directly from the source, rather than from the perspective
of mental health clinicians, which may be distorted or skewed. For example, the findings
of the study suggest a difference in clinicians’ perspectives regarding PTSD symptom
severity based on their level of education, gender, and military status. Based on these
findings, the researchers’ recommend that future studies examining clinicians’
perspectives also include a comparison with the veteran clients’ perceptions, in order to
determine whether discrepancies in perspective exists between the two groups.
Furthermore, it would be beneficial for future studies to expand their data collection to
include a larger sample size, which would be more indicative of the larger veteran
population.
In addition, expanding the sample to include a broader range of professionals that
would be more likely to encounter veterans utilizing positive coping styles would be
more representative of the overall population. Collecting data from other sources besides
mental health clinicians would increase the probability that data would include veterans
who are coping well with their trauma. By limiting the study to mental health
professionals who work with veterans seeking treatment, it is understandable that
veterans encountered in this setting would be more likely to experience lower levels of
functioning and maladaptive coping styles. Future studies may benefit from expanding
the sample to include professionals such as chaplains, pastors, and family members. This
may capture more responses that are representative of veterans who are positively coping
with their trauma through use of religion or social support.
71
In addition to expanding the research sample to capture professionals who are
more likely to encounter adaptive coping styles, it is recommended that future studies
explore specific adaptive coping styles that may have implications for successful
outcomes among veterans. The findings suggest the use of self-narratives, based on
professionals’ perspectives regarding the treatment of trauma, were associated with the
lowest levels of symptom severity (estimated marginal mean, 44.18) and among the
highest levels of social functioning (estimated marginal mean, 32.79). Accordingly, the
authors’ recommend that future studies focus on the use of self-narratives and narrative
therapy in the treatment and management of trauma within the veteran population.
Social support was also associated with successful outcomes in regards to
symptom severity (estimated marginal mean, 44.94), and social functioning (estimated
marginal mean, 31.01). As discussed in the literature review, the positive implications of
social support have been researched extensively in regards to treatment for the veteran
population (Benetato, 2011; Pietrzak et al., 2011; Resnick, Bradford et al., 2012).
Therefore, the researchers recommend future studies evaluate and examine the
effectiveness of programs that incorporate social support into their treatment for veterans.
For example, future studies can explore the implications that peer-based support
programs and family therapy have on treatment outcomes for trauma exposed veterans.
The authors’ of the current study recommend an examination of preventative
efforts in addressing military trauma for future research. Further recommendations for
future research include exploring the effectiveness of preventative measures and
screening tools to address combat stress and trauma. Examining the effectiveness of
72
preventative measures may indicate a relationship between proactive approaches to
trauma and positive coping, or decreased rates of PTSD diagnoses. This understanding
may provide useful information to the military, which could cut health care costs and
improve the mental health of veterans and military service members. The current study,
which is representative of other studies, focuses on reactive measures by examining
veterans with a pre-existing diagnosis that are coping with trauma. There is a lack of
research focusing on pre-mental health screenings and preventative measures in the
military population. This mentality coincides with the general American approach to
healthcare and mental health, which is generally reactive rather than proactive (Sayer, et
al., 2010).
Limitations
Many studies have inherent limitations in their design or data collection methods.
Often times these limitations become clear after the completion of the study. As
discussed in chapter one a main limitation of the current study is that members of the
veteran population themselves were not surveyed, and responses were limited to mental
health professionals working with the population. Furthermore, due to the risks of
administering an online survey with minimal oversight and in person contact between the
researchers and participants, the data collected is dependent on the honesty of the
participants in regards to their qualifications and demographic information. Sample size
is an important indicator of the ability to generalize a study’s findings from the sample to
the larger overall population.
73
The current study is limited due to the small sample size of 33 participants. In
addition, of the 33 participants only 28 fully completed the survey from start to finish.
Due to the small sample size, it was difficult for the researchers to run comprehensive
statistical tests that require a larger sample size. Furthermore, the study was limited
because of missing variables. The study design allowed participants to only respond to
particular coping styles, which they had encountered in their practice, leaving an unequal
number of responses per question. This flaw in the study design resulted in missing
variables that made certain statistical analysis and comparison difficult or impossible to
achieve. Furthermore, this resulted in a discrepancy in the number of overall responses
for positive and negative coping styles.
The discrepancy in the number of responses between positive and negative coping
styles is likely due to the sample of participants in the study. To elaborate further,
because the study included mental health professionals working with veterans with
PTSD, it is assumed that the samples of professionals were more likely to encounter
veterans who were coping poorly with their trauma. Accordingly, those veterans who are
high functioning and utilize positive coping techniques may not seek treatment from
mental health clinicians. Therefore, more professionals answered questions regarding
negative coping styles then positive, resulting in a discrepancy between the responses for
these two categories.
The study design asked participants to generalize their responses to be most
representative of overall trends in their veteran clients. This generalization did not allow
for demographic nuances and differences to be accounted for or examined. Therefore,
74
information that could be indicative of how varying demographic groups within the
veteran population may cope differently with trauma is not included. Differences in
coping styles, social functioning, and symptom severity based on the veterans’ gender,
ethnicity, age, number of deployments, types of trauma, and, type of military service may
have produced varying outcomes had this information been accounted for.
Conclusion
Traditional mental health interventions used within the veteran population tend to
focus on symptom management and medical model approaches to the treatment of PTSD.
As a result, there tends to be less emphasis on prevention and adaptive ways of coping
with trauma. This traditional model tends to lack development in areas of “recovery”
approaches to treatment and strengths based therapeutic methods and interventions. The
current study findings suggest that the incorporation of psycho-education, peer based
programs, and positive coping skills into treatment interventions could have positive
implications for the management of trauma for veterans. More specific to the current
study, the findings imply that positive coping styles are associated with lower levels of
symptom severity and higher levels of social functioning. Organizations and clinicians
that treat veteran can utilize this information to craft more effective interventions and
identify areas for improvement within existing programs.
75
Appendix A
Human Subjects Review Approval Letter
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
To: Julia Leonardi-Holzapfel & Catherine Brown
Date: 10/24/2012
FROM: Committee for the Protection of Human Subjects
RE: YOUR RECENT HUMAN SUBJECTS APPLICATION
We are writing on behalf of the Committee for the Protection of Human Subjects from
the Division of Social Work. Your proposed study, “Professional’s Perspectives on How
Veterans Manage Trauma in the Context of Posttraumatic Stress Disorder.”
__X_ approved as _ _ X _EXEMPT _ __ NO RISK ____ MINIMAL RISK.
Your human subjects approval number is: 12-13-023. Please use this number in
all official correspondence and written materials relative to your study. Your
approval expires one year from this date. Approval carries with it that you will
inform the Committee promptly should an adverse reaction occur, and that you
will make no modification in the protocol without prior approval of the
Committee.
The committee wishes you the best in your research.
Professors: Maria Dinis, Jude Antonyappan, Teiahsha Bankhead, Serge Lee, Kisun Nam,
Maura O’Keefe, Dale Russell, Francis Yuen Cc: Russell
76
Appendix B
Introduction Letter and Consent to Participate
Dear Participants:
The information gathered from this survey will be used to identify best practices for
treating Veterans diagnosed with Post-Traumatic Stress Disorder (PTSD). The data
gathered will help identify differential coping styles and the relationship between PTSD
symptomology and social functioning. The survey will take approximately 30 minutes to
complete. Please generalize your responses to represent the majority of Veterans with
PTSD whom you have worked with. The researchers are second year Master’s of Social
Work students (at Sacramento State) working on their thesis project.
The researchers expect the information gathered will encourage the development of more
effective and nuanced tools for assessment, evaluation, and treatments for Veterans
diagnosed with PTSD. Any identifying information will be coded to protect your privacy
and will be kept confidential. An informed consent is included at the start of the survey
and you will receive an e-gift card upon completion of the survey.
Please feel free to contact the researchers Catherine Brown and Julia Holzapfel (MSW II
Graduate Students) via email at cab916@xxxxx.com
Thank you for your participation!
(Please copy and paste the link into your internet browser to ensure that it opens
correctly).
https://www.surveymonkey.com/s/3H5D3XS
**Please pass this email along to anyone you know who has worked with Veterans and
may be interested in participating.
77
Consent to Participate
*1. Consent to Participate in a Study on Professionals’ Perspectives on How Veterans
Manage Trauma within the Context of Post Traumatic Stress Disorder
I hereby agree to participate in a study entitled, "Professionals’ Perspectives on How
Veterans Manage Trauma within the Context of Post Traumatic Stress Disorder” and I
understand that the participation in the study involves the following: Completing a survey
and agreeing to the terms of this informed consent form.
Why is this study being conducted?
This study is conducted by Catherine Brown and Julia Holzapfel, MSW II students of
California State University, Sacramento to find out why Veterans develop differential
coping styles in the face of trauma and how this impacts their social functioning and
PTSD symptom severity. I have been requested to take part in this study because I can
provide information on this topic since I work with this particular population.
What am I being asked to do?
I will be one of about respondents in the area who will be asked to complete a short
survey with my perspective on how Veterans manage their trauma, and how their coping
styles affect their social functioning and PTSD symptom severity. I will be asked what
some people consider to be sensitive questions about my best practices in working with
Veterans who have traumatic experiences. The questionnaire may generally take about 30
minutes to complete.
Is this voluntary?
Yes. I am under no obligation to participate. When I agree to participate, I can ask skip
any questions on the survey that I'd rather not answer. I am also free to stop the survey at
any time.
What are the advantages of participating?
Participating in this study will be instrumental in crafting effective treatments in the
Veteran population. This will be beneficial to both the population being studied, and the
professionals who work with trauma exposed Veterans. I will also receive a $5 incentive
for participating in this study as a token of appreciation for my time.
Is this confidential?
Yes. Nothing learned about me by the researchers will be disclosed. The study will
remove identifying information from the data collected through the survey. All records
will be identified only by a number, and the link between that number and my name will
be kept in a locked file that is available only to the principal investigators. At the
completion of the study all identifying information will be destroyed and only the
compiled content of the surveys will be kept. Everything I say will be strictly confidential
and any reports or other published data based on this study will appear only in the form
78
of summary statistics or condensed account without the names of or other identifying
information about the participants.
What risks do I face if I participate?
There are no risks expected as the researcher is trained to ask the questions in a way that
ensures my dignity and privacy and I have the right not to answer any question that I do
not want to answer.
Who do I contact if I have questions about this research?
If I have any questions about the study, I can ask the researcher via email at
cab916@xxxxx.com or faculty advisor Dr. Dale Russell via email at
Drussell@saclink.csus.edu
By clicking “next” I consent to be interviewed, that I can print this consent form, and that
I read, understood, and agreed to the terms.
Researchers: Catherine Brown and Julia Holzapfel
I Accept
79
Appendix C
On-Line Survey
PART I
Please fill out the following questions regarding demographic information.
There are nine questions regarding demographic information.
3. What is your email address? The researchers will email you an e-gift card upon
completion of the survey.
4. Please select your gender:
Male
Female
5. Please identify your level of education in mental health:
Other
MSW
MFT
LMFT
PhD.
PsyD.
M.D.
Other
LCSW
6. How many years of experience do you have working with Veterans with PTSD?
0-5
5-10
7. Have you ever served in the U.S. military?
10-15
No
Yes
Active Duty
8. In what setting do you (or have you in the past) treat Veterans?
15+
Veteran
9. About how many Veterans have you treated total?
0-10
10-25
25-50
50-100
10. About what percentage of your current caseload are Veterans?
25%
50%
75%
100+
100%
80
PART II
Definitions of Coping Styles
For the purpose of this study a definition of terms included in the following survey are
defined on each page. Please take time to review the definitions as the researchers have
defined each coping style for this study. Please identify which coping style(s) you have
seen with your clients and go to the appropriate questions containing that coping style(s).
The participant ONLY needs to answer the questions that reference that specific coping
style(s).
There are 24 total questions remaining for the survey. However, it is unlikely that you
will have to answer all of the questions.
For example, if you have seen Cognitive Avoidance and Religious/Spiritual Coping then
respond ONLY to the following questions that reference Cognitive Avoidance and
Religious/Spiritual Coping.
81
Instructions
When answering the following questions please consider any U.S. Veterans diagnosed
with PTSD (as a result of war trauma) that you have treated in a mental health setting
within the past ten years.
The survey questions on the following pages are constructed from a modified version of
the PTSD Checklist-Military Version and a modified version of the Social Functioning
Questionnaire. Please generalize your responses in a way which is representative of
trends seen in the majority of Veterans you have treated.
NOTE: Please identify which coping style(s) you have seen with your clients and go to
the appropriate questions containing that coping style(s). The participant ONLY needs to
answer the questions that reference that specific coping style(s).
82
11. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize ANGER
AND DISSOCIATION as their primary coping method in response to military
trauma?
DEFINITION: Anger is a form of emotional disengagement that is characterized by
increased or impulsive aggression; whereas dissociation is a form of emotional
disengagement in which experiences, emotions and cognitive processes are not
consciously recognized (Kulkarni, Porter & Rauch, 2012).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient of
a stressful military experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble breathing,
or sweating) when something
reminded the patient of a stressful
military experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient of
a stressful military experience?
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience were
happening again (as if the patient
were reliving it)?
83
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
12. Which aspects of social functioning are affected in patients who utilize ANGER
AND DISSOCIATION as their primary coping method in response to military
trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
o
o
o
o
Moderate
Problems
o
o
o
o
Occasional
Problems
o
o
o
o
No
Problems
at all
o
o
o
o
84
o
o
o
o
o
o
o
o
o
o
o
o
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
13. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize PTG
(POST-TRAUMATIC GROWTH) as their primary coping method in response to
military trauma?
DEFINITION: Positive self discovery following a traumatic experience resulting in
personal growth and adaptive coping (Benetato, 2011;Sinclair, 2012).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
85
patient were reliving it)?
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
86
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
14. Which aspects of social functioning are affected in patients who utilize PTG
(POST-TRAUMATIC GROWTH) as their primary coping method in response to
military trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
87
o
Emotional regulation
o
o
o
15. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
BEHAVIORAL AVOIDANCE (WITHDRAWAL) as their primary coping method
in response to military trauma?
DEFINITION: Behavioral avoidance is escaping stressful situations or activities by
means of social withdrawal (Pietrzak, Harpaz-Rotem, & Southwick, 2011).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
88
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
16. Which aspects of social functioning are affected in patients who utilize
BEHAVIORAL AVOIDANCE (WITHDRAWAL) as their primary coping method
in response to military trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
o
o
Moderate
Problems
o
o
Occasional
Problems
o
o
No
Problems
at all
o
o
89
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
17. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
POSITIVE RELIGIOUS/SPIRITUAL COPING as their primary coping method in
response to military trauma?
DEFINITION: Positive religious and spiritual coping is defined as, “seeking spiritual
support, collaboration with God in solving the problem, and positive religious appraisals
of the problem” (Witvliet et al., 2004, p. 271).
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
o
o
o
o
o
90
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
91
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
18. Which aspects of social functioning are affected in patients who utilize
POSITIVE RELIGIOUS/ SPIRITUAL COPING as their primary coping method in
response to military trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
92
o
o
o
o
o
o
o
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
19. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
COGNITIVE AVOIDANCE as their primary coping method in response to military
trauma?
DEFINITION: Cognitive avoidance is characterized by avoidance or denial of thoughts
related to a traumatic experience (Pietrzak et al., 2011).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
Feeling very upset when
something reminded the patient
of a stressful military
experience?
93
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
94
20. Which aspects of social functioning are affected in patients who utilize
COGNITIVE AVOIDANCE as their primary coping method in response to military
trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
21. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
POSITIVE BEHAVIORAL APPROACHES as their primary coping method in
response to military trauma?
95
DEFINITION: In contrast to withdrawal and isolation, positive behavioral approach
strategies include things such as reaching out to others, supporting peers, and coming
together as Veterans through shared experiences (Mattocks et al., 2011).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
96
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
22. Which aspects of social functioning are affected in patients who utilize
POSITIVE BEHAVIORAL APPROACH strategies as their primary coping method
in response to military trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
97
o
o
o
o
o
o
o
o
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
23. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
SUBSTANCE ABUSE as their primary coping method in response to military
trauma?
DEFINITION: Substance abuse is defined as a “maladaptive pattern of substance use
manifested by recurrent and significant adverse consequences related to the repeated use
of substances” (APA, 2000, p. 198).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
Feeling very upset when
something reminded the patient
98
of a stressful military
experience?
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
99
Feeling jumpy or easily startled?
o
o
o
o
o
24. Which aspects of social functioning are affected in patients who utilize
SUBSTANCE ABUSE as their primary coping method in response to military
trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
25. Answer the next two questions ONLY if you have seen this particular coping
style.
100
Which aspects of PTSD symptomology are affected in patients who utilize SELFNARRATIVES as their primary coping method in response to military trauma?
DEFINITION: Self-narratives involve the process of constructing a positive self identity
following trauma. This can be accomplished through self disclosure, acceptance of the
trauma experienced, creation of positive identity post trauma, and self reflection through
storytelling, disclosure, or by confronting trauma in a supported environment (Aiello,
2010; Benetato, p. 14, 2011; Fox & Pease, 2012; Stansbury, Mathewson-Chapman, &
Grant, 2003).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing
memories, thoughts, or images
of a stressful military
experience?
o
o
o
o
o
Repeated, disturbing dreams
of a stressful military
experience?
o
o
o
o
o
Suddenly acting or feeling as
if a stressful military
experience were happening
again (as if the patient were
reliving it)?
o
o
o
o
o
Feeling very upset when
something reminded the
patient of a stressful military
experience?
o
o
o
o
o
Having physical reactions
(e.g., heart pounding, trouble
breathing, or sweating) when
something reminded the
patient of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or
talking about a stressful
military experience or avoid
having feelings related to it?
o
o
o
o
o
101
Avoid activities or situations
because they remind the
patient of a stressful military
experience?
o
o
o
o
o
Trouble remembering
important parts of a stressful
military experience?
o
o
o
o
o
Loss of interest in things that
the patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling as if the patients’
future will somehow be cut
short?
o
o
o
o
o
Trouble falling or staying
asleep?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling irritable or having
angry outbursts?
Having difficulty
concentrating?
Being “super alert” or
watchful on guard?
Feeling jumpy or easily
startled?
26. Which aspects of social functioning are affected in patients who utilize SELFNARRATIVES as their primary coping method in response to military trauma?
Severe
Problems
Ability to complete tasks at home
o
Moderate
Problems
o
Occasional
Problems
o
No
Problems
at all
o
102
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
27. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize
SUICIDAL IDEATIONS AND/OR ATTEMPTS as their primary coping method in
response to military trauma?
DEFINITION: Suicidal ideations are thoughts about taking one’s own life and attempts
are concrete actions to take one’s own life.
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
o
o
o
o
o
103
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
104
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
28. Which aspects of social functioning are affected in patients who utilize
SUICIDAL IDEATIONS AND/OR ATTEMPTS as their primary coping method in
response to military trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
o
o
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
o
o
105
o
o
o
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
29. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize SOCIAL
SUPPORT as their primary coping method in response to military trauma?
DEFINITION: Also in contrast to withdrawal and isolation, social support is used as a
coping method when social relationships are strengthened and maintained in the face of
trauma. This can be either in familial or peer relationships, and often self disclosure is
involved.
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
106
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
30. Which aspects of social functioning are affected in patients who utilize SOCIAL
SUPPORT as their primary coping method in response to military trauma?
Severe
Problems
Moderate
Problems
Occasional
Problems
No
Problems
at all
107
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
31. Answer the next two questions ONLY if you have seen this particular coping
style.
Which aspects of PTSD symptomology are affected in patients who utilize RISK
TAKING BEHAVIORS as their primary coping method in response to military
trauma?
DEFINITION: Intentional behaviors that result in negative outcomes such as over use of
substances, possession of weapons, and engaging in violent behavior (Strom et al., 2012).
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
108
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
109
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
32. Which aspects of social functioning are affected in patients who utilize RISK
TAKING BEHAVIORS as their primary coping method in response to military
trauma?
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
110
o
o
o
o
o
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
33. Answer the next two questions ONLY if you have seen a particular coping style
not mentioned above.
Which aspects of PTSD symptomology are affected in patients who utilize
________________ (if applicable please insert a coping style that was not mentioned
above in the text box at the bottom of this page) as their primary coping method in
response to military trauma?
Not
Affected
Mildly
Affected
Moderately
Affected
Strongly
Affected
Extremely
Affected
Repeated, disturbing memories,
thoughts, or images of a stressful
military experience?
o
o
o
o
o
Repeated, disturbing dreams of a
stressful military experience?
o
o
o
o
o
o
o
o
o
o
Feeling very upset when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Having physical reactions (e.g.,
heart pounding, trouble
breathing, or sweating) when
something reminded the patient
of a stressful military
experience?
o
o
o
o
o
Suddenly acting or feeling as if a
stressful military experience
were happening again (as if the
patient were reliving it)?
111
Avoid thinking about or talking
about a stressful military
experience or avoid having
feelings related to it?
o
o
o
o
o
Avoid activities or situations
because they remind the patient
of a stressful military
experience?
o
o
o
o
o
Trouble remembering important
parts of a stressful military
experience?
o
o
o
o
o
Loss of interest in things that the
patient used to enjoy?
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Feeling distant or cut off from
other people?
Feeling emotionally numb or
being unable to have loving
feelings for those close to the
patient?
Feeling as if the patients’ future
will somehow be cut short?
Trouble falling or staying
asleep?
Feeling irritable or having angry
outbursts?
Having difficulty concentrating?
Being “super alert” or watchful
on guard?
Feeling jumpy or easily startled?
34. Which aspects of social functioning are affected in patients who utilize
________________ (if applicable please insert a coping style in the text box that was
not mentioned above at the end of this page) as their primary coping method in
response to military trauma?
112
Severe
Problems
Ability to complete tasks at home
Occupational/employment
Intimacy in relationships
Sexual functioning
Finances
Relationships with family and relatives
Relationships with friends
Quality of social interactions
Isolation
Housing
Legal problems
Substance abuse
Goal setting
Life satisfaction
Anhedonia
Emotional regulation
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Moderate
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Occasional
Problems
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
No
Problems
at all
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
113
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