PROVIDERS’ PERCEPTIONS AND TREATMENT APPROACHES FOR
AMERICAN VETERANS REPORTING SYMPTOMS OF POST-TRAUMATIC
STRESS DISORDER
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
Ann-Alecia L. Brewer
SPRING
2014
PROVIDERS’ PERCEPTIONS AND TREATMENT APPROACHES FOR
AMERICAN VETERANS REPORTING SYMPTOMS OF POST-TRAUMATIC
STRESS DISORDER
A Project
by
Ann-Alecia L. Brewer
Approved by:
__________________________________, Committee Chair
Maria Dinis, Ph.D., MSW
____________________________
Date
ii
Student: Ann-Alecia L. Brewer
I certify that this student has 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.
__________________________, Graduate Coordinator
Dale Russell, Ed.D., LCSW
Division of Social Work
iii
___________________
Date
Abstract
of
PROVIDERS’ PERCEPTIONS AND TREATMENT APPROACHES FOR
AMERICAN VETERANS REPORTING SYMPTOMS OF POST-TRAUMATIC
STRESS DISORDER
by
Ann-Alecia L. Brewer
This study aims to examine providers’ beliefs and perceptions and best treatment
approaches regarding post-traumatic stress disorder as it pertains to Operation Enduring
Freedom and Operation Iraqi Freedom. This qualitative exploratory content analysis
study utilizes a planned behavior and symptoms theory approach. Data was collected
through an open-ended question interview of 10 mental health practitioners selected
through snowball sampling design. Three main themes emerged: 1) technology and
environment role in manifestation of post-traumatic stress disorder symptoms, 2) how
post-traumatic stress disorder may relate to increased acts of violence in Veterans, and 3)
the use of multi-modal treatment approaches and practitioner perceived barriers to
treatment. Implications for social work practice and policy are discussed.
_______________________, Committee Chair
Maria Dinis, Ph.D., MSW
_______________________
Date
iv
ACKNOWLEDGMENTS
I would like to thank my family and friends for their continuous support as
I pursued this chapter of my life. Without the reassurance, positive feedback, late night
phone calls, and much needed distractions this project would not have been possible. The
journey has been complicated and unpredictable, but with their support it has been well
worth the adventure. I would also like to thank you my employers and clinical supervisor
for supporting me in finishing this project and believing in my future.
Additionally, I would like to acknowledge my professors and field supervisors for
helping me gain confidence, understanding, and patience. I would also like to give
gratitude to the clients that I had the privilege to work with for opening up their lives to
me and teaching me what it means to work in this profession. I remain gracious for each
of them sharing their stories with me.
This project is dedicated to the women and men who have served in the United
States Armed Forces. I am thankful to have been able to experience the stories of
Veterans in various moments of my life and am grateful to have had this opportunity to
contribute to the dialogue of mental health needs for Veterans. I would like to thank all
of the clinicians that allowed me to listen to their stories and supported me in my
endeavor.
Lastly, I dedicate this project to the lost and the hopeful. To those who are still
searching for their passion; to those who realize they lost theirs. To the twists and turns of
the human condition.
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TABLE OF CONTENTS
Page
Acknowledgments......................................................................................................... v
Chapter
1. INTRODUCTION……………………………………………………………….. 1
Background of the Problem ............................................................................. 2
Statement of the Research Problem ................................................................ 3
Purpose of the Study ....................................................................................... 4
Research Question……………………………………………………………4
Theoretical Framework .................................................................................. 5
Definition of Terms ........................................................................................ 9
Assumptions…………………………………………………………………10
Justification ................................................................................................... 10
Delimitations ................................................................................................. 12
Summary…………………………………………………………………….12
2. REVIEW OF THE LITERATURE ...................................................................... 14
Historical Background ................................................................................... 14
Post-Traumatic Stress Disorder ..................................................................... 16
Evidenced Based Interventions ..................................................................... 21
Barriers to Treatment..................................................................................... 25
Gaps in the Literature .................................................................................... 31
Summary ....................................................................................................... 34
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3. METHODOLOGY ............................................................................................... 35
Introduction………………………………………………………………....35
Research Question…………………………………………………………..35
Research Design .............................................................................................35
Study Population ............................................................................................38
Sampling Procedures………………………………………………………...39
Instrumentation ...............................................................................................39
Data Gathering Procedures .............................................................................41
Data Analysis .................................................................................................42
Protection of Human Subjects ........................................................................42
Summary ....................................................................................................... 43
4. DATA ANALYSIS ............................................................................................... 44
Introduction………………………………………………………………….44
Participant Demographics……………………………………………………45
Impact of Technology and Environment ....................................................... 45
Pot-Traumatic Stress Disorder and Acts of Violence……………………….48
Multi-Modal Treatment Approaches and Barriers to Treatment................... 53
Summary ........................................................................................................59
5. CONCLUSIONS AND RECOMMENDATIONS ............................................... 60
Introduction…………………………………………………………………60
Conclusions………………………………………………………………….60
vii
Recommendations…………………………………………………………...63
Limitations..................................................................................................... 65
Implications for Social Work Practice and Policy…………………………...65
Conclusion ..................................................................................................... 67
Appendix A. Sacramento State IRB Approval ......................................................... 69
Appendix B. Consent to Participate in Research ...................................................... 71
Appendix C. PTSD and Veterans Practitioner Survey ............................................. 74
References ................................................................................................................... 76
viii
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1
Chapter 1
INTRODUCTION
Currently it is estimated that approximately fifteen percent of service men and
women will be diagnosed or experience symptoms of post-traumatic stress disorder after
serving in Operation Iraqi Freedom and Operation Enduring Freedom Wars (Ramchand,
Karney, Osilla, Burns, & Calderone, 2008). While post-traumatic stress disorder has
long been associated with military involvement under different names (e.g. shellshock),
in recent years there has been much interests in assisting Veterans in receiving access to
mental health treatment and exploring what factors contribute to the onset of posttraumatic stress disorder.
Soldiers are at risk of developing mental health and physical issues due to
stressful living conditions, the nature of military warfare, and heightened states of stress
over extended periods of time (Litz, 2007). More than ever, service members have
access to stressors at home as well due to advancements in technology which may
provide a unique stress on the battle field that was not there before. Modern warfare has
also changed including the use of improvised explosive devices. Though multiple
attempts are made at screening soldiers for post-traumatic stress disorder indicators,
services for symptoms of post-traumatic stress disorder are highly underutilized by
returning service members.
2
Background of the Problem
To date, the Department of Defense requires all returning service members to
complete a Post-Deployment Health Assessment to measure for factors contributing to
post-traumatic stress disorder. Approximately, one quarter of service members who
acknowledge mental health difficulties will seek treatment (Hoge & Castro, 2006). The
Department of defense utilizes evidenced based treatment approaches to treat symptoms
of post-traumatic stress disorder. Treatments include the use of eye movement
desensitization and reprocessing, cognitive behavioral therapies, group processing
therapy, and pharmacotherapy. Pharmacotherapy may be prescribed by the Veterans
primary physician without the service member participating in mental health treatment
such as cognitive based therapy.
There is an underutilization of mental health services by the Veterans who
experience symptoms of post-traumatic stress disorder (Office of Public Health and
Environmental Hazards, Veterans Health Administration, 2010). There are numerous
reasons as to why Veterans do not seek mental health resources while serving in the
military as well as after deployment. Operation Enduring Freedom and Operation Iraqi
Freedom Veterans have listed barriers to include: being seen as weak, being treated
differently by peers and leadership, questioning of ability to lead or perform duties of the
job, and beliefs regarding the effectiveness of treatment (Hoge et al., 2006). Many
service members feel that treatment would not be useful to them, and that they can
alleviate their symptoms better through self-care techniques. There are also logistical
3
barriers to treatment including access to transportation or proximity to services,
appointment compaction at Veteran’s health centers, and ability to receive adequate care.
Currently the Department of Defense requires all returning service members to be
screened using a Post-Deployment Health Screening in order to gauge for mental health
symptoms and needs (Prins et al., 2003). The Department of Defense and Veteran
Administration utilize evidenced based practice approaches to work with Veterans
experiencing symptoms of post-traumatic stress disorder. These therapeutic practices
include cognitive behavioral therapy, eye movement desensitization and reprocessing,
psychoeducation, group therapy, and pharmacotherapy. Limited amounts of sessions are
provided for the various treatment approaches. Pharmacotherapy has been successful in
treating physical symptoms of post-traumatic stress disorder; however, medication cannot
change the mental aspect of experiencing post-traumatic stress disorder such as
ruminating on thoughts of combat or decreasing night terrors. More information is
needed regarding the best treatment approaches for treating symptoms of post-traumatic
stress disorder with Operating Enduring Freedom and Operation Iraqi Freedom Veterans.
Statement of the Research Problem
This research will study professionals whom are currently working or have
previously worked with military Veterans. It aims to explore best therapeutic approaches
to use with Veterans experiencing symptoms of post-traumatic stress disorder who have
served in the Operation Enduring Freedom and Operation Iraqi Freedom wars. In
4
addition, this research will explore common symptoms of post-traumatic stress disorder
reported by Veterans and possible reasons for post-traumatic stress disorder onset.
Purpose of the Study
The purpose of this study is to explore mental health providers’ perceptions and
beliefs about American Veterans from Operation Iraqi Freedom and Operation Enduring
Freedom who are reporting symptoms of post-traumatic stress disorder, including
treatment approaches to best serve this population. With this assessment, the researcher
hopes to identify a best treatment approach that will specifically help Operation Iraqi
Freedom and Operation Enduring Freedom Veterans based on the unique needs of this
population. The purposes of this research are as follows:
1.) To identify most common symptoms experienced by Operation Iraqi Freedom and
Operation Enduring Freedom Veterans.
2.) To identify factors contributing to the onset of post-traumatic stress disorder in
Operation Iraqi Freedom and Operation Enduring Freedom Veterans.
3.) To identify best clinical treatment approaches to treating post-traumatic stress
disorder in military Veterans.
Research Question
This study investigates the following research question: What are mental health
providers’ perceptions of post-traumatic stress disorder and beliefs regarding best
treatment approaches for American Veterans who served or are serving in the Operation
Iraqi Freedom and Operation Enduring Freedom wars?
5
Theoretical Framework
There are two theoretical frameworks that guide this study. The first theory is
planned behavior and the second is systems theory.
Planned Behavior
In identifying barriers to seeking treatment by Operation Iraqi Freedom and
Operation Enduring Freedom Veterans, a framework using the theory of planned
behavior is helpful in understanding an individual’s behavior in making choices
regarding treatment seeking and participation. Planned behavior theory proposes that
human behavior is guided by three factors: (1) beliefs about the likely consequences of
the behavior (i.e. stigma regarding mental health, perceived weakness), (2) beliefs about
the normative expectations of others, and (3) beliefs about the presences of factors that
may help or prevent performance of the behavior (Ajzen, 1991). According to this
theory, “the more favorable the attitude and subjective norm and the greater the perceived
control, the stronger should be the person’s intention to perform the behavior”
(Hardeman, Johnston, Johnston, Bonetti, Wareham, & Kinmonth, 2002, p.156).
This theory proposes that a person’s decision to engage in a behavior is linked to
the person’s beliefs about the behavior (Stecker, Fortney, Hamilton, & Ajzen, 2007). For
example, if a Veteran views seeking treatment as beneficial they will be more likely to
seek out treatment. However, if a Veteran views seeking mental health services as a
negative action, the Veteran will be less likely to seek out mental health services.
Another factor of planned behavior theory is that it involves a perceived behavioral
6
control from the consumer or person displaying the behavior (Hardeman, Johnston,
Johnston, Bonetti, Wareham, & Kinmonth, 2002). A person must feel like they have
some type of control over the behavior in question in order for planned behavior theory to
manifest.
Application of Planned Behavior.
If Veterans exhibit the three factors listed
previously, they may be more likely to seek and participate in mental health treatment.
Many Veterans report perceived stigma and preferring self-help to professional treatment
as barriers to seeking clinical treatment. By being able to modify elements of planned
behaviors for this population, treatment providers may be able to increase engagement
and utilization of services for Operation Enduring Freedom and Operation Iraqi Freedom
Veterans.
Using planned behavior theory is beneficial in this study specifically around how
mental health practitioners can form their practices in a way that Veterans will view it as
beneficial for them to seek out treatment. If practitioners can help to alleviate some of
the perceived stigma around mental health treatment, Veterans would be more willing to
participate in treatment because they may feel more positively about the behavior
internally. This may, in turn make treatment for symptoms of post-traumatic stress
disorder more effective.
Systems Theory
When investigating best clinical treatment approaches for post-traumatic stress
disorder, it is imperative to incorporate a foundation based upon systems theory. Systems
7
theory is comprised on studying social groups and their interaction with one another, with
an emphasis on the individual’s additional unique environmental factors. By
incorporating factors of systems theory, a better understanding of individual problems in
relation to larger social institutions and communities can be discovered (Greene, 2008).
Systems theory relies on the tenets of structure, function, and process. Structure
is comprised of components and relationships between components; function is the
outcome, or the results of the relationship between components; and process is the
sequence of events and knowledge that produce the function (Ing, 2013). Through the
interaction of parts, system theory strives to improve delivery of outcome whether it is
service based or knowledge based. Ing also notes that a system is a configuration of
people, information, and technology that creates value between a provider and recipient
through a service. For purposes of this study, the Veterans Administration is the provider
with military Veterans being the recipients of services. Effective care and most beneficial
use of limited resources is vital when multiple services are working together to provide
services (Batten & Pollack, 2008).
Application of Systems Theory. In particular, systems theory will assist in
exploring how institutions like the Department of Defense or Veterans Administration
can support or hinder a Veteran experiencing post-traumatic stress disorder in seeking
services. The military’s system of care is comprised of multiple sectors within the
system in which navigation of services can be difficult. By using a systems theory
framework, one can explore how the multiple systems Operation Enduring Freedom and
8
Operation Iraqi Freedom Veterans communicate with one another, and how the systems
can improve in order to increase access to services for Veterans.
Integrated care is important for Veterans experiencing symptoms of posttraumatic stress disorder because often they may have co-occurring disorders such as
substance abuse or physical health challenges. Communication between systems when
treating mental health and physical health is imperative in treating this population, and
helping Veterans to make the transition back into civilian life. In order for services to be
beneficial, service providers need to have an understanding of systems in which the
Veteran receives services, services offered to the Veterans, and ability to access or make
referrals to services as deemed appropriate. In order for services to be rendered and
beneficial, Veterans will need to have an understanding of the military network or care
and how to maneuver within it.
When studying post–traumatic stress disorder and treatment approaches, both
theories incorporate a necessity to explore the individual’s beliefs regarding utilization of
care and the institutions in which care is sought out. In these systems the researcher will
be exploring individuals, system, and cultural factors directly related to Veterans
experiencing symptoms of post-traumatic stress disorder and seeking treatment.
Preliminary research reveals that multiple barriers exist for Veterans seeking treatment
including stigma, access to services, and denial of mental health problems (Schell &
Marshall, 2008). Both of these theories will comprise the theoretical lens the researcher
will use when approaching this study.
9
Definition of Terms
This study focuses on challenges that pregnant teens encounter and aims to
explore education and its connection to support for pregnant youth, therefore, teens will
most likely be in some sort of school setting or environment that focuses on education.
In referring to certain terms throughout this work, the following definitions are assumed

Veteran – a person who has served in the military forces (Collins English
Dictionary, 2009).

Service member – individual currently serving in the United States Military
(Office of Public Health and Environmental Hazards, Veterans Health
Administration, 2010).

Mental health clinician/service provider- a physician, psychiatrist, etc (MSW,
LCSW, MFT, LMFT), who specializes in clinical work as opposed to one
engaged in laboratory or experimental studies. (Collins English Dictionary, 2009).

OEF – Operation Enduring Freedom (Office of Public Health and Environmental
Hazards, Veterans Health Administration, 2010).

OIF – Operation Iraqi Freedom (Office of Public Health and Environmental
Hazards, Veterans Health Administration, 2010).

Post-traumatic stress disorder-- the development of characteristic symptoms
following exposure to an extreme traumatic stressor involving direct personal
experience of an event that involves actual or threatened death or serious injury,
or other threat to one’s physical integrity; or witnessing an event that involves
10
death, injury, or a threat to the physical integrity of another person; or learning
about unexpected or violent death, serious harm, or threat of death or injury
experienced by a family member or other close associate (American Psychiatric
Association, 2000).
Assumptions
The researcher has developed a list of assumptions to be considered in this study.
These assumptions are as follows: 1) Mental health clinicians have a sound
understanding of the symptoms and criteria of post-traumatic stress disorder; 2) Mental
health clinicians employed by the Veterans Administration will have similar levels of
training in utilized practice approaches; 3) The Veterans Administration and Department
of Defense provide trainings for evidence based therapeutic approaches when working
with Veterans experiencing symptoms of post-traumatic stress disorder; 4) Multiple
factors contribute to the manifestation of post-traumatic stress disorder symptoms in
Operation Enduring Freedom and Operation Iraqi Freedom Veterans; and 5) Veterans
participating in treatment provide honest answers and feedback during therapy.
Justification
This mental health provider assessment study was developed in order to gain a
better understanding of factors impacting post-traumatic stress disorder in Veterans from
the Operation Enduring Freedom and Operation Iraqi Freedom wars in order to better
serve service members mental health needs. With this assessment, the researcher aims to:
identify if practitioner belief regarding best practice approaches for post-traumatic stress
11
disorder are in line with treatment approaches utilized by Veterans Administration
currently and to discover what symptoms of post-traumatic stress disorder are most
readily reported by Operation Enduring Freedom and Operation Iraqi Freedom Veterans.
It is hoped that the findings of this study will contribute to the research data
focused on Operation Enduring Freedom and Operation Iraqi Freedom Veterans in order
to provide better services for mental health needs in order to help these Veterans make a
safe transition back into civilian life. This study may help to raise questions and
awareness regarding best treatment approaches for Veterans experiencing post-traumatic
stress disorder in order to increase the likelihood of Veterans seeking mental health
treatment, and increase success rates in minimizing symptoms of post-traumatic stress
disorder.
This study will support current and future social workers in maintaining the
ethical principles of service and competence as outlined in the Nation Association of
Social Workers Code of Ethics (2008). Social workers aim to help people overcome
struggles that impact their daily lives including hardships related to mental health
disorders. The Code of Ethics (2008) states that “social workers draw on their
knowledge, values, and skills to help people in need and to address social problems”.
The growing diagnosis of post-traumatic disorder is a social problem that is not limited to
the military population. Information gained in this study may help to provide service to
military personnel experiencing symptoms of post-traumatic stress disorder as well as
persons diagnosed in the general public.
12
Social worker competence outlines that “social workers practice within their areas
of competence and develop and enhance their professional expertise” (Nation Association
of Social Workers Code of Ethics, 2008). It is unethical for practitioners to work with
clients experiencing post-traumatic stress disorder without the proper training and
knowledge of practice approaches to meet the client’s needs. This study identifies best
treatment approaches for post-traumatic stress disorder which will provide practitioners
an avenue to developing competency in practice techniques.
Delimitations
Information retrieved in this study is limited to the small population of Veterans
in multiple placements that have had varying degrees of experience working with
Veterans experiencing symptoms of post-traumatic stress disorder. As noted in the
literature, various factors contribute to the onset of post-traumatic stress disorder as well
as multiple treatment approaches for alleviating symptoms of post-traumatic stress
disorder. Themes found within contributing factors and treatment approaches are based
on the opinion of the small number of clinicians interviewed for this study. The
researcher utilized open ended questions for survey response which allows for a varied
range of answers to research questions.
Summary
This chapter presents an introduction to the study that included the background of
the problem, the purpose for the study, and the research question. Also presented were
the theoretical frameworks, definition of terms, and researcher assumptions. In
13
conclusion, delimitations were addressed followed by a summary. The following chapter
will provide a review of the literature, including the prevalence of post-traumatic stress
disorder in military Veterans, currently practiced treatment approaches, and identified
barriers to treatment. Chapter three will describe the methodology for the study. Chapter
four will examine and analyze the data collected. Lastly, chapter five will include a
summary and discussion of the major finding of the study as well as provide
recommendations and implications for the social work profession.
14
Chapter 2
REVIEW OF THE LITERATURE
The review of the literature is broken up into six major headings: (1) Historical
Background of Post- Traumatic Stress Disorder; (2) Post-Traumatic Stress Disorder; (3)
Evidence Based Interventions; (4) Barriers to Treatment; and (5) Gaps in the Literature.
Under these headings, additional findings will be organized using the following themes:
(1) Prevalence; (2) Trauma Categories and Measurements; (3) Eye Movement
Desensitization and Reprocessing; (4) Cognitive Behavioral Therapy; (5)
Pharmacotherapy; (6) Veteran Perceived Barriers to Accessing Treatment; and (7)
System of Care Needs and Enhancements. This chapter ends with a summary.
Historical Background
Before the Vietnam War, post-traumatic stress disorder was not yet the name
defining the negative mental experiences of men returning from combat. Symptoms of
war experienced by Veterans were referred to as shell shock before psychological
research was performed leading to the accepted psychiatric term post-traumatic stress
disorder. Shell shock was believed to be caused by neurons disrupted in the brain by
artillery blasts or sensory overstimulation (Lerner, 2003). During early wars, technology
like MRIs and CAT scans did not exist so evidence of brain damage was left unforeseen.
Soldiers reported symptoms of amnesia, poor concentration, headache, tinnitus,
hypersensitivity, dizziness and tremors (Jones, Fear, & Wessely, 2007). During this time,
shell shock was seen as an organic problem versus a psychological problem. Unlike the
15
stigma perceived with post-traumatic stress disorder, shell shock was surrounded with
much less stigma due to being perceived as a wound or injury (Jones, Fear, & Wessely,
2007). Some did perceive shell shock in having a component of psychiatric basis
including Myers (1940) who described it as hysteria, neurasthenia, or psychiatric illness
that could be caused by soldiers suffering emotional stress (p.8).
After service men started returning home from Vietnam it came to the attention of
the United States military that the mental side effects of war experienced by many
soldiers returning home were making it difficult for them to transition back into their
civilian lifestyles. Due to this, the United States military began focusing on more research
of the disorder that is now known as post-traumatic stress disorder. Many were
experiencing flashbacks and “reliving” their experiences in combat. Today as service
men and women are returning from the wars in Iraq and Afghanistan approximately
fifteen percent will experience symptoms related to post-traumatic stress disorder
(Ramchand et al., 2010). Many are being diagnosed with post-traumatic stress disorder
or the more prevalently used diagnosis of acute stress disorder due to long deployments
in the war. However, the treatment of PTSD and the prevention of its symptoms are still
fairly new. Approximately one quarter to one half of returning service members who
acknowledge mental health concerns seek mental health treatment. One connection that
may be missing for these service members who do not readily seek treatment is the early
detection of symptoms due to numerous barriers of seeking treatment (Hoge et al., 2006).
Too often members of the armed forces are being sent back into warfare without
16
receiving much needed mental health treatment to ensure their mental health is adequate
to return to combat.
The most recent wars in Iraq and Afghanistan have produced an increasing
amount of Veterans returning home with symptoms of posttraumatic stress disorder.
These soldiers are at risk of developing chronic mental illness as a result of harsh
elements, inconsistencies regarding “enemies”, and a heightened state of stress for long
periods of time (Litz, 2007). It has also been recognized that there are unique patterns of
readjustment back to civilian life that depend on war stressors one is exposed to
including, “military sexual trauma, witnessing others injured/killed, and being injured”
oneself (Katz, Cojucar, Davenport, Pedram, & Lindl, C., 2010).
Post-Traumatic Stress Disorder
Post-traumatic stress disorder is defined by the DSM-IV-R (American Psychiatric
Association, 2000) as,
the development of characteristic symptoms following exposure to an extreme
traumatic stressor involving direct personal experience of an event that involves
actual or threatened death or serious injury, or other threat to one’s physical
integrity; or witnessing an event that involves death, injury, or a threat to the
physical integrity of another person; or learning about unexpected or violent
death, serious harm, or threat of death or injury experienced by a family member
or other close associate (p.463).
17
Members of the Armed Forces are exposed to traumatic stressors as normal part of their
duties while serving. Service members experience danger for themselves as well as here
about incidents with fellow service members, civilians, and war opponents.
Criteria for post-traumatic stress disorder (PTSD) states, “a person is exposed to
a traumatic event, the traumatic event is persistently reexperienced, persistent avoidance
of stimuli associated with the trauma and numbing of general responsiveness, persistent
symptoms of increased arousal, duration of the disturbance is greater than one month, and
the disturbance causes significant distress or impairment in occupational, social, or
important areas of functioning” (American Psychiatric Association, 2000; p.467-468).
If stressors last less than a month, Veterans are diagnosed with Acute Stress Disorder
which has many of the same criteria for PTSD.
Prevalence. The American Psychiatric Association estimates that approximately
eight percent of adults in the United States meet the criteria for PTSD (American
Psychiatric Association, 2000, p.468). According to the Office of Public Health and
Environmental Hazards (2010), Veterans Health Administration, of the veterans who
served in Operation Iraqi Freedom and Operation Enduring Freedom and accessed health
services at various Department of Veterans Affairs medical offices, one quarter have
been diagnosed with post-traumatic stress disorder with that number growing as more
Veterans return from war and access services. Multiple studies have been conducted
measuring variables that contribute to the onset of post-traumatic symptoms including
military branch and rank, length of deployments, multiple deployments, intensity of
18
exposure to combat (e.g. firsthand, secondhand), and status of mental health prior to
enlistment and deployment (Ramchand, Schell, Karney, Osilla, Burns, & Calderone,
2010).
Trauma Categories and Measurements. For the purpose of this study, trauma
events as they affect Operation Iraqi Freedom (OIF) and Operation Enduring Freedom
(OEF) Veterans will be defined through four main categories which include: episodes of
extraordinarily abusive violence, traditional combat events, harsh working or living
environment, and perceived threat to self or others (King, King, Gudanowski, & Vreven,
1995). Other categories that can contribute to the onset of post-traumatic stress disorder
for some Veterans include concerns about life and family disruptions, sexual harassment
or threat, general harassment from colleagues, and biological problems resulting from
exposure to foreign substances. Episodes of extraordinarily abusive violence can include
instances of abuse violence against civilians or trainees, overt brutality, and so forth as
reported in a study by Greenberg and Dratel (2005). Although there has been limited
data identifying the prevalence of such actions within the war zone, a survey conducted
by the U.S. Department of the Army, Office of the Surgeon General (2006b)found that
four percent of soldiers and seven percent of Marines reported acting overly physical
aggressively with noncombatant individuals when it was unwarranted.
Traditional combat events include, “being injured or wounded in combat; killing,
injuring, or wounding someone else; and handling or smelling dead and decomposing
bodies” (Killgore, Cotting, Thomas, Cox, McGurk, Vo, & Hoge, 2008, p.1119). These
19
may be everyday occurrences for deployed military personnel which can contribute to the
likelihood of manifesting symptoms of post-traumatic stress disorder once deployed into
a more normalized, less hostile environment. The military personnel serving in the
Operation Enduring Freedom and Operation Iraqi Freedom wars experience harsh living
conditions including, but not limited to, concerns regarding food and air quality, insect
endemics or parasite exposure, lack or privacy or personal space, and environment borne
illnesses (Helmar, Rossignol, Blatt, Agarwal, Teichman, & Lange, 2007). Service
members deployed to the desert were also exposed to extreme heat, wind storms, and
other harsh elements of nature that can cause strain on the body and psyche during
deployment.
The last category, perceived threat to self or others, is a dominate theme in the
OIF and OEF wars. In a survey conducted by Kolkow, Spira, Morse, and Grieger (2007),
medical personal reported that they frequently felt they were in personal danger (38%) or
were frequently concerned about dying (approximately 25%) while performing military
duties. One of the experiences that contributes to the perceived threat to self or others is
the exposure to others who have been injured or witnessing someone inflict injury, seeing
deceased people, or coming in to harm’s way oneself (i.e. IEDs, combat fire) (U.S.
Department of the Army, 2006b).
According to research conducted by Litz in 2007, service members are living
through violence at increasing rates due to advancements in medical technology and
protective gear. However, service members are seeing immense amounts of violence and
20
injuries that affect their morale and increase levels of anxiety. Litz reports that exposure
to death, witnessing the aftermath of violence, and seeing human remains has been shown
to be linked to an increase of anxiety, anger and aggressive behavior, somatic complaints,
and PTSD (p.1676). He also found that Veterans returning home who were experiencing
the greatest distress reported concern of being stigmatized as a barrier to receiving mental
health counseling.
Some current research studies have focused on aggression as a way of emotional
regulation and some researchers believe this may help to account for why some people
experiencing symptoms of PTSD may be more likely to act out in violence as a response
to their emotional dysregulation. The researchers found that previous exposure to
interpersonal violence that led to symptoms of PTSD has the possibility of producing
“severe disruption in emotional experience, prompting a rigid reliance on maladaptive
coping strategies” (Tull, Jakupcak, Paulson, & Gratz, 2007, p.338).
So far most of the research focus has been placed on male service members
diagnosed with posttraumatic stress disorder. Hamilton, Goff, Crow, and Reisberg
(2009) explored the symptoms of military trauma on female partners of those deployed in
the war. The study consisted of forty-five Army couples where the male partner was
deployed to Iraq or Afghanistan. They found that women who experienced trauma related
to the re-experience of PTSD of their partners and arousal symptoms had decreased
satisfaction in their relationships for both partners. This is to mention that PTSD can
cause mental hardships for those experiencing trauma first hand as well as those in
21
interaction with them. Another study looked at the separation and homecoming of
military personnel and wives. It was found that longer deployments led to association
with increased psychological distress for the spouse (de Burgh, White, Fear, & Iversen,
2011).
Evidence Based Interventions
Upon returning from deployment, the Department of Defense requires all
returning service members to complete a Post-Deployment Health Assessment, and to
complete Post-Deployment Health Reassessment three to six months after initial
screening both consisting of four yes or no questions in which answering yes to three
warrants further questioning about post-traumatic stress disorder symptomology (Prins,
Oiumette, Kimerling, Camerond, Hugelshofer, Shaw-Hegwer, & Sheikh, 2003). Upon
further assessment, mental health clinicians use strategies of report building, structured
clinical interviews, self-report measures and questionnaires, and assess for comorbidity.
However these processes take time, and some Veterans may be weary to participate in
services due to stigma, preoccupation in other areas of life, time constraints, and
resistance or motivation to change (Hoge, Castro, Messer, McGurk, Cotting, & Koffman,
2004).
Further research must be conducted the best possible treatment for Veterans who
served in Operation Iraqi Freedom and Operation Enduring Freedom experiencing
symptoms of PTSD. Recent data suggests that fifteen percent of service members
returning from the Iraq and Afghanistan Wars have been diagnosed with posttraumatic
22
stress disorder (Yarvis, 2011). More and more veterans are getting diagnosed as the wars
go on. It is increasingly important that mental health care workers are knowledgeable on
how to work with this population. PTSD can impair social relationships, reduce
intimacy, and increase propensity for violence. Interventions need to be focused on an
inclusive model that looks at multiple areas of one’s life and the clients’ interaction in the
environment.
Eye Movement Desensitization and Reprocessing. Currently a treatment that is
being used is eye movement desensitization and reprocessing which has clients recall
traumatic events while focusing on a rapidly moving object (Garske, 2011). Eye
Movement Desensitization and Reprocessing is a technique created by Francine Shapiro
that requires the client exhibiting symptoms of post-traumatic stress disorder to identify
distressing trauma memory images, identify related negative and positive cognitions, and
become aware of the physical anxiety response. This technique involves asking the client
to hold the three prior stated elements in mind while tracking the therapists’ finger
movements (Shapiro, 1989). Recent studies have shown however that finger movements
may not be necessary for the client to begin desensitization and that other forms of
alternating stimulation (e.g. tapping) may provide the same results (Spates, Koch, Cusak,
Pagoto, & Waller, 2009). Comparisons by Spates et al. have also indicated that eye
movement desensitization and reprocessing is comparable in effectiveness to treating
post-traumatic stress disorder as prolonged exposure to trauma therapy.
23
Cognitive Behavioral Therapy. Cognitive behavioral therapy utilizes different
techniques to help those suffering from symptoms of post-traumatic stress disorder. The
belief behind these techniques is that events may manifest cognitively for an individual
with erroneous thought patterns of belief regarding the stimuli. Therefore, the goal of the
therapy is to change the thought patterns regarding the stimuli, or trauma, which will in
turn influence the individual’s behaviors (Elhers & Clark, 2000). A variation on
cognitive behavioral therapy called cognitive processing therapy has an exposure
component in which individuals “challenge faulty assumptions and self-statements and to
modify maladaptive thoughts and overgeneralized beliefs in the areas of safety, trust,
power and control, esteem, and intimacy,” which has been effective in treating symptoms
of post-traumatic stress disorder in female and male veterans (Monson, Schnurr, Resick,
Friedman, Young-XU, & Stevens, 2006, p.900).
Other types of psychotherapy that are currently used to treat post-traumatic stress
disorder in Veterans include group therapy, hypnosis, and psychodynamic therapy.
Group can be beneficial because it highlights commonalities between individuals and can
be used as an additional support space. A group setup can also offer varied techniques
and cover a broad range of topics. Groups can be an effective setting for offering
psychoeducation about post-traumatic stress disorder as well as teaching coping
mechanisms. Hypnosis and psychodynamic therapy are currently not utilized as often as
a treatment approach through military systems of care due to the length needed to deliver
these treatment approaches and lack of empirical evidence equivalent to other treatment
24
approaches such as cognitive behavioral therapy for treating symptoms of post-traumatic
stress disorder.
Pharmacotherapy. The use of psychotropic medication as a treatment option is
widely used in the mental health field to assist in treating many psychological disorders
including post-traumatic stress disorder. Benefits of utilizing pharmacotherapy include
normalization of taking medication as opposed to psychotherapy, availability of receiving
a prescription for medication versus obtaining cognitive behavioral therapy due to
availability of services, and medication can be used to treat comorbidity diagnoses
(Feeny, Zoellner, Mavissakalian, & Roy-Byrne, 2009). Antidepressants and
antiadrenergic agents have been used to treat symptoms of post-traumatic stress disorder.
Antidepressants in the form of selective serotonin reuptake inhibitors have shown
to be beneficial in treating the anxiety like symptoms often experienced with posttraumatic stress disorder. As demonstrated in a study by Londberg, Hegel, Goldstein,
Himmelhoch, Maddock, and Farfel (2001), thirty percent of patients participating in the
study self-reported a decrease in trauma re-experiencing, avoidance of arousal stimuli,
decrease in hyperarousal symptoms, and seem to have improvement in overall quality of
life. The research conducted by Friedman and Davidson (2007) highlights that selective
serotonin reuptake inhibitors may not be as effective in treating post-traumatic stress
disorder due to combat trauma, as they can be treating post-traumatic stress disorder in
civilians. The use of antiadrengic agents to treat symptoms of post-traumatic stress
disorder were found to be effective in treating nightmares experienced by Veterans who
25
served in the Vietnam War (Kolb, Burris, & Griffths, 1984). Research has not yet
indicated whether antiadrengic agents are effective in treating other symptoms of posttraumatic stress disorder.
While there are no studies to date that have evaluated the benefits or success of
using pharmacotherapy and psychotherapy in conjunction with one another, Veterans
experiencing symptoms of post-traumatic stress disorder are often treated with both
treatment approaches through the VA healthcare centers. Pharmacotherapy can be
beneficial at treating physiological symptoms of post-traumatic stress disorder, however
it cannot provide long term benefits psychologically of working through the trauma as a
cognitive based method of psychotherapy will be able to do. When used in conjunction,
pharmacotherapy and psychotherapy can be beneficial in helping Veterans from the
Operation Enduring Freedom and Operation Iraqi Freedom wars at finding relief from
their symptoms of post-traumatic stress disorder.
Barriers to Treatment
Many Veterans of the Operation Enduring freedom and Operation Iraqi Freedom
wars come back from deployment with mental health needs. The Armed Forces, in
addition to numerous studies, have attempted to discover what possible barriers exist to
the OEF and OIF Veterans seeking treatment of mental health services after returning
from being deployed. Data particular to this group of Veterans indicates that on average
those Veterans that are diagnosed with PTSD are more likely to have an overall poorer
general health (Jakupcak, Luterek, Hunt, Conybeare, & McFall, 2008). The Department
26
of Veterans Affairs reports “almost 50% of Veterans presenting to VA health care
facilities report pain, with the majority presenting with a combination of pain, depression,
and PTSD” (Seal, Metzler, Gima, Bertenthal, Maguen, & Marmar, 2008, p.714).
Utilization of services also varies between branches and gender. For example, according
to a study conducted by Schell and Marshall (2008), service members activated from the
National Guard or Reserves have a higher likelihood of reporting mental health
symptoms than regular active duty service members. On average only approximately one
fourth to one half of service members who acknowledge that they are experiencing
mental health symptoms will see mental health treatment (Hoge et al., 2006). Of those
service members who do seek treatment, only about thirty percent receive minimally
adequate treatment for symptoms of post-traumatic stress disorder which Schell and
Marshall defined as eight thirty minute sessions of psychotherapy or four visits with a
doctor for medication management (Schell & Marshall, 2008).
Veteran Perceived Barriers to Accessing Treatment. Several studies have
focused specifically on barriers to treatment by Operation Enduring Freedom and
Operation Iraqi Freedom Veterans. A 2004 study discovered research participants widely
endorsed feelings that “they would be perceived as weak, be treated differently by
leadership, and that treatment would result in others having less confidence in them”
(Hoge et al.). Service member leaders in higher ranks may feel that seeking treatment
would result in their ability to lead to come into question; again harping on the perception
of being looked at as weak. The feeling of being seen as weak is problematic for
27
Veterans as they work in a team atmosphere where they must rely on one another for
support and safety. In a study conducted by the RAND Corporation of active duty and
Veterans from the Operation Iraqi Freedom and Operation Enduring Freedom wars,
survey respondents listed barriers falling into the following three categories: (1) logistical
barriers (i.e. transportation difficulty, difficulty scheduling appointments, (2) institutional
and cultural barriers, and (3) beliefs regarding effectiveness of treatment (Schell &
Marshall, 2008).
Vogt, Bergeron, Salgado, Daley, Ouimette, and Wolfe (2006) discovered that
personal factors of Veterans, such as wanting to solve the problem themselves or
believing the problem would go away, were greater barriers to care than logistical factors
like travel. Women Veterans reported a lack of women specific services as a major
barrier to seeking services for mental health treatment. In conclusion of most studies
developing data on barriers to care, it is necessary to note that many Veterans feel that
seeking treatment will reflect directly on them in a negative way. Mental health services
are underutilized by returning Operation Enduring Freedom and Operation Iraqi Freedom
service members due primarily to stigma centered primarily on diagnoses and perceived
inability to be an effective soldier.
Overcoming Barriers to Treatment. Anderson’s (1995) Behavioral Model of
Health Services finds that a person’s intention to perform a behavior is linked to the
amount of perceived control and favorable attitude towards the subjective norm. This
means that if an Operation Enduring Freedom or Operation Iraqi Freedom Veteran feels
28
favorable to the idea of seeking treatment and has an intention to seek treatment, that
person will be more likely to follow through on seeking out treatment for mental health
services. Stecker, Fortney, Hamilton, and Ajzen (2007) found that respondents in their
study on barriers to mental health treatment found that many soldiers did not expect to
have a struggle with their mental health, and they would prefer to engage in self-care
techniques rather than seek treatment from a mental health professional. Perhaps if
mental health treatment for post-traumatic stress disorder for Veterans began focusing on
psychoeducation and self-care, a higher rate of Veterans would engage in professional
mental health services.
Both the Department of Defense and the Department of Veterans Affairs have
allocated an increased amount of funding to study new treatments for post-traumatic
stress disorder in order to find a treatment approach that is effective for Veterans and that
will increase the likelihood of service members seeking mental health treatment for their
symptoms. A program that the Depart of Defense is working on is called Warrior
Resiliency Training. The program focuses on service members perceptions regarding
mental health treatment in response to war training, and it recognizes that skills useful to
soldiers during war time may be problematic in civilian life (Adler, Bliese, McGurk,
Hoge, & Castro, 2009). Lastly, another intervention that has been trialed by Veterans
with symptoms of post-traumatic stress disorder is internet based cognitive behavioral
therapy. This method has shown success in a small clinical trial; however, more research
and larger trial sizes would need to be conducted to more accurately measure the level of
29
success with the program (Litz, Engel, Bryant, & Papa, 2007). Online treatment may
prove to be beneficial as society has grown exponentially in the use of internet based
applications. It may also help to diminish some of the barriers to Operation Enduring
Freedom and Operation Iraqi Freedom Veterans seeking out mental health treatment
upon returning from deployment.
System of Care Needs and Enhancements. The military is comprised of
multiple branches, military bases, and centers for medical treatment all over the world.
This makes for a huge and complex healthcare system for Veterans to navigate in order to
get help they need. The United States military healthcare system is comprised of the
following: the Department of Defense healthcare facilities, TRICARE, the Veterans
Health Administration of the Department of Veterans Affairs, and various public and
private treatment centers that work to provide care to Veterans as they return from war.
Due to the complexity of the system, Veterans often see multiple doctors over the course
of treatment which could possibly be a barrier to receiving adequate treatment for mental
health needs.
It is important that practitioners working with Veterans exhibiting symptoms of
post-traumatic stress disorder be knowledgeable about the population they are working
with, have adequate training in clinical interventions that are beneficial to treating posttraumatic stress disorder, and collaborate readily with the Veteran seeking services and
other systems of care to ensure that needs are being met (Adler, Kwon, and Singer,
2005). In order for the Department of Defense to have some type of consistency with the
30
vast amount of practitioners they employ, the use of decision trees are used in a clinical
setting to help ensure that practitioners learn which techniques should be utilized in the
treatment of post-traumatic stress disorder (VA/DoD Clinical Practice Guideline
Working Group, 2004). The Department of Defense and Veterans Administration
healthcare systems also train clinicians to use evidenced based interventions as cognitive
processing therapy, prolonged exposure therapy, and cognitive behavioral therapy to treat
symptoms of post-traumatic stress disorder.
In order for mental health practitioners to be successful in treating Veterans with
post-traumatic stress disorder they need to have a basis of knowledge that incorporates
understanding of military culture, treatments for post-traumatic stress disorder, military
and Veteran benefits, resources available to Veterans through the military and the public,
and ability to make referrals to necessary resources. It has also been shown to be
beneficial for practitioners to have interpersonal support from other practitioners and
clinical supervisors to combat compassion fatigue, secondary trauma, and other risks
associated with counseling trauma clients (Bride, 2004). Being able to process through
experiences in the clinical setting will be beneficial for the practitioner to help combat the
fore-mentioned, which will in turn be more useful to the Veteran seeking mental health
treatment due to having a mental health practitioner who is able to provide appropriate
care.
For those military personnel seeking treatment outside of the Department of
Defense or Veterans Affairs healthcare systems, adequate treatment may be less
31
accessible as often clinicians in the general public may not be aware of military resources
or norms, and may not be adequately trained to provide clinical interventions for treating
post-traumatic stress disorder. It is beneficial for the military service member to inform
treatment providers that they are military personnel in order to bring more awareness to
their unique healthcare needs. Family support is also very valuable to Veterans
experiencing symptoms of post-traumatic stress disorder as family members will spend
the most time with the Veteran and can learn tools to assist the Veteran with managing
symptoms of post-traumatic stress disorder (Batten, Drapalski, Decker, DeViva, Morris,
Mann & Dixon, (2009). Due to recent laws, family centered treatment focused on
providing relief from post-traumatic stress disorder symptoms is becoming more readily
available through the Veterans Administration (Government Accountability Office,
2008).
Gaps in the Literature
Research regarding post-traumatic stress disorder in Operation Enduring Freedom
and Operation Iraqi Freedom Veterans is still fairly new as the wars themselves are
recent. More research will need to be conducted in order to properly assess patterns of
post-traumatic stress disorder in these recent Veterans to be able to better assist them in
treating symptoms of post-traumatic stress disorder as well as possibly providing predeployment safe guards to decrease the number of service members who will be
susceptible to experiencing negative symptoms associated with serving in war. As more
knowledge is gained through the use of research studies, the Department of Defense and
32
Veterans Administration will be able to more accurately serve those who are serving their
country.
One major gap in the literature is the lack of studies that focus on identifying
factors of service members including but not limited to: military branch, gender, age, race
and ethnicity. More research focused on studying how these different factors impact the
experience of service members in the Operation Enduring Freedom and Operation Iraqi
Freedom war may provide insight on how experiences vary and impact members as well
as possibly provide a picture of susceptibility to post-traumatic stress disorder. With
more specific date, the military may be able to better serve current and returning service
members.
Currently, most of the research for this population is focused on Veterans
returning from the Operation Iraqi Freedom and Operation Enduring Freedom wars,
which is also the focus of this study. However, there is little research on service
members who are currently serving within the wars and mental health needs. It would be
beneficial to conduct mental health research before service members enter deployment,
during deployment, and after deployment to get a more accurate picture of how posttraumatic stress disorder manifests in this population. Long term studies can be
problematic due to loss or participants throughout the study and lack of resources.
Treatment for post-traumatic stress disorder through the Department of Defense
focuses on cognitive based therapies for treatment. Though evidenced based, practice
approaches are not a one size fits all. It is important to be aware how culture plays into
33
engagement in treatment and treatment approach fit in order to best serve the needs of the
person seeking treatment. Treatment for Veterans is also short in nature regarding
psychotherapy, and often Veterans may never see a mental health professional; rather to
be treated by a doctor through the use of psychotropic medication.
Another gap in the literature, which is the basis for this study, is what are
practitioner beliefs regarding treatment and post-traumatic stress disorder for Veterans of
the Operation Enduring Freedom and Operation Iraqi Freedom wars. Not only is
research lacking in particular to the most recent wars, but no research known to this
writer has primarily focused on the beliefs of practitioners towards better treatment
approaches. It would be beneficial to see what practitioners’ perceptions of treatment
approaches utilized by the military healthcare avenues are, and whether they disagree or
not, how this impacts their treatment work with Veterans of the Operation Iraqi Freedom
and Operation Enduring Freedom wars. It is also important to know what patterns
practitioners are seeing in regards to post-traumatic stress disorder symptoms and causes
as they have firsthand knowledge of what Veterans (who seek treatment) are reporting
versus what might be answer bias on surveys or brief mental health assessments.
This writer’s research study aims to fill in the gap of research regarding
practitioners’ beliefs of the prevalence of post-traumatic stress disorder in Operation
Enduring Freedom and Operation Iraqi Freedom Veterans. Through these research
findings, the researcher will be able to derive common beliefs held by mental health
practitioners about onset of post-traumatic stress disorder as well as best practice
34
approaches for treatment of Veterans experiencing symptoms. It is the hope of this
researcher that the study findings will contribute to the knowledge base of finding best
treatment approaches for serving Veterans with post-traumatic stress disorder.
Summary
This chapter reviewed literature in relation to Veterans experiences of posttraumatic stress disorder and best treatment approaches for post-traumatic stress disorder.
The following topics were detailed: description of post-traumatic stress disorder;
prevalence of post-traumatic stress disorder in Veterans; evidenced based interventions
currently used to treat post-traumatic stress disorder; perceived barriers to treatment;
system of care needs and enhancements; and gaps in the literature. The following chapter
will outline the methodology applied in this project.
35
Chapter 3
METHODOLOGY
Introduction
In this chapter, the methodology and research design utilized for this project is
described. The author explains the methods used in the design of the study and the
analysis of the interviews, describes criteria for selecting the participants, details of the
interview process, and defines the development of the interview questions. The chapter
sections included: Research Question, Research Design, Study Population, Sample
Population, Instrumentation, Data Gathering Procedure, Data Analysis, and Human
Subjects.
Research Question
The research question investigated in the study is as follows: What are mental
health providers’ perceptions of post-traumatic stress disorder and beliefs regarding best
treatment approaches for American Veterans who served or are serving in the Operation
Iraqi Freedom and Operation Enduring Freedom wars?
Research Design
This research project uses a qualitative exploratory design. Content analysis was
used. A qualitative approach is utilized due to the subjective nature of the research study
as a way to explore beliefs held by practitioners about the population they serve. The
researcher finds it appropriate to use a qualitative content analysis due to the variance of
responses collecting data in a narrative approach through open-ended survey questions.
36
After the data is compiled, the researcher will look for common themes in responses that
have been reported by the participants.
Qualitative Content Analysis. Qualitative content analysis classifies data
according to categories that are organically derived from the data being studied
(Damschroder & Damschroder). This type of analysis is used to discover patterns,
themes, and word meanings in the data in order to draw conclusions regarding the subject
being studied (Denzin & Lincoln, 2005). The goal of qualitative inquiry is to understand
a phenomenon or topic rather than making generalizations to the greater population based
on statistical inference (Damschroder & Damschroder, 2008).
Examples of this given by the Damschroders include understanding processes such as
delivery of health care services, capturing the experiences of participants, and explaining
what those experiences mean. This type of analysis allows the researcher to go into more
depth around the subject matter of post-traumatic stress disorder and treatment
approaches because “Qualitative content analysis examines data that is the product of
open-ended data collection techniques aimed at detail and depth, rather than
measurement” (Damschroder & Damschroder, 2008, p.41). Qualitative research allows
participants to explain and expand on the answers they provide with will allow the
research to extract more meaning from the provided information (Denzin & Lincoln,
2005).
Content analysis describes content as either latent or manifest. Latent content
refers to the underlying meaning of words that that you are analyzing or simply put
37
unobservable data. Manifest content is observable data that is taken at face value (Gray
& Densten, 2008). One issue with using latent content as a coding technique is that it is
open to bias by the researcher as they are determining the meaning from the data, but this
may not be what is the meaning. Manifest content is taken at face value but there may be
more meaning to it that would not be recognized if that was the only way of viewing it.
An advantage of utilizing manifest and latent content analysis, is that it can find
interpretation and meanings in words that could have otherwise been lost, for instance, on
a quantitative survey.
One disadvantage of qualitative research is that it is subjective. Research is
gathered based on the opinions of the research participants and therefore can rarely be
generalized to a larger population. During the analysis, researcher bias is naturally
inserted due to the subjective coding of the researcher based on how he or she places
emphasis on words or phrases. Qualitative research is also very hard to duplicate due to
the organic production of material by a small, specific group of people. You will never
be able to get the same answers twice, even if you were to interview the same people
(Denzin & Lincoln, 2005).
Data Management. The researcher utilized direct contact between the research
participants to produce complex data in the participants own words. Each participant has
a unique story and experience that is more accurately captured through qualitative
research methods. After information was gathered, the researcher transcribed each
interview in order to prepare the data for coding. Some drawbacks to qualitative content
38
analysis are that it can be time consuming to conduct interviews and transcribe them,
finding ways to analyze data can be overwhelming depending on content volume, and
researcher bias may come into effect with how the data is being viewed (Damschroder &
Damschroder, 2008, p.41).
In this research study, codes are derived from the data itself in order to find
meaning in the context of participant answers (Hsieh & Shannon, 2005). As the
researcher develops preliminary themes, data will be examined again to find further
themes within themes in order to find evidence of best practice approach and
commonalities between participants answers regarding post-traumatic stress disorder.
Study Population
Participants of this qualitative study are mental health practitioners currently
working or who have worked with the Veterans providing therapeutic services to
American Armed Forces veterans or practitioners who have had past experience working
with OIF and OEF veterans. The participants have had experience working with veterans
from the OIF and OEF wars and may have experience working with Veterans from
previous wars such as Vietnam or World War II. The focus of the interview is to
understand what beliefs or perceptions practitioners possess about post-traumatic stress
disorder and violence, and how these beliefs may affect their practice techniques with the
Veterans with which they work. Participants will provide the researcher with insight
regarding best treatment approaches for alleviating symptoms of post-traumatic stress
disorder.
39
Sampling Procedures
Snowball sampling was used to recruit participants for the research study. The
researcher contacted the suicide prevention coordinator for the VA Northern California
Health Care System who agreed to refer clinicians for the research study. Four
participants offered to refer qualified participants to the researcher to take part in the
study. The sample size was a total of ten participants. The advantages of snowball
sampling are that one can get a specific type of participant because the person who refers
them will know what the study is about and can deem if the person they refer is an
appropriate fit. With random sampling, for example, one does not know any type of
background of the participants or whether they can offer any helpful information on the
topic being studied (Rubin & Babbie, 2008).
The downfalls to snowball sampling include your referral line ending either due to
lack of available participants or unwillingness of a current participant to refer a person to
your study. Also, there may be a possibility that snowball sampling can change the
validity of the study if a past participant tells a new participant what to expect on the
survey. In this manner answers may not be as organic due to the respondent having
previous time to think about what they would answer for each question (Rubin & Babbie,
2008).
Instrumentation
The researcher conducted audio recorded interviews asking participants to answer
ten standardized open-ended questions to gather data (See Appendix C). The researcher
40
delivered the questions clearly, repeating the questions if there was confusion. Three
questions asked participants about best treatment approaches for post-traumatic stress
disorder. Two questions asked the participants to give responses regarding symptoms of
post-traumatic stress disorder. One question asked about trends of post-traumatic stress
disorder in the OIF and OEF wars, and then another question asked the participants to
compare this with their opinion on post-traumatic stress disorder in past wars. The two
final questions asked about their personal experience working with Veterans.
The interviews lasted approximately fifteen minutes to forty minutes. At the conclusion
of the open-ended question part of the interview, participants were instructed to fill out
demographic information on the top of the interview sheet. Interviews were conducted at
a time and location convenient for each participant. In order to maintain validity of the
survey instrument, the questions were standardized prior to engaging in any interviews.
The interviewer took care not to vary from the words used in the questions and did not
provide conversation during the length of the interview. This allowed all participants the
opportunity to give their opinions on the same matters. Open ended questions allow the
respondent to provide as much detail as they would like and allow for a wide range of
answers. A disadvantage to this however is that it interrupts the natural flow of a
conversation by providing parameters which in to provide feedback (Gray & Densten,
2008).
The interview process is similar to maintaining a professional conversation. At
all times, the researcher shall conduct themselves in a professional manner by being
41
timely to the interview, dressing professionally, and being properly prepared for the
interview. The researcher should maintain interest in what the participant is saying in the
interview and provide feedback as appropriate in a manner that will not affect the study
outcome. At all times, it is important for the interviewer to maintain professionalism and
politeness with the interview participant and thank them for taking time to participate in
the study.
Data Gathering Procedures
The researcher was referred participants through the suicide prevention
coordinator for the VA Northern California Health Care System via an email sent out to
possible participants that included information on the study and contact information for
the researcher. Initial interested participants contacted by the researcher to set up a
convenient time for the interview. Each participant was provided with a copy of the
consent form upon meeting with the researcher to be signed prior to the start of the
interview (See Appendix B). The participants were interviewed in a location safe for
them; primarily in their offices.
At the start of the interview, the researcher reviewed the Consent to Participate in
Research form with the participant. After the form was signed, the participants were
asked to answer ten open-ended questions verbally asked by the researcher. Each
interview was recorded using a digital audio recorder. The surveys were given an
identifiable number to be matched up with the audio recording. The interviews were
approximately fifteen to forty minutes in duration. At the completion of the interview,
42
participants received a $10 Starbucks gift card to thank them for their participation in the
research study. Three participants out of ten accepted the gift card. The researcher
offered to notify participants of research findings after completion of the study and made
contact available should they have any questions or concerns following the interview. At
the completion of each interview, the researcher asked participants to forward the
information about the study and the contact information of the researcher to anyone they
felt would be an appropriate candidate for the study.
Data Analysis
At the completion of each interview, audio recordings were transcribed into a
word processing document and printed for analysis. Data was analyzed for themes,
concepts, commonalities, differences, and connection of ideas. The researcher organized
data by themes to conduct a content analysis. Key words of common themes were
highlighted as the researcher focused on each passage. This classification was useful in
summarizing insight into best practice approaches and manifestations of symptoms of
post-traumatic stress disorder as viewed through the lens of mental health practitioners.
Both manifest and latent content analysis were used. Common themes were developed
and described within the context of existing literature and the theoretical frameworks
reviewed for this study.
Protection of Human Subjects
Prior to the start of data collection, the researcher submitted a Request for Review
by the California State University, Sacramento Division of Social Work Research Review
43
Committee. The application was approved as exempt, approval number 12-13-048. No
participants were contacted prior to approval. Consent forms were signed by participants
prior to conducting interviews.
Participants were advised that their participation was voluntary and that they
could withdraw from the research study at any time. They were also advised that they
could refuse to answer any question or end the interview at any time. Participants were
advised of the study process and confidentiality in the Consent to Participate in Research
form (See Appendix B). Consent forms and information obtained from the study were
stored in a confidential secure location in the researcher’s home.
Each participant was assigned a “pseudo” name in order to assure their
anonymity. The participants were also instructed prior to the start of the recording to not
use any identifying monikers of patients or themselves. Printed documentation as well as
information stored on the researcher’s computer including e-mail contact was destroyed
after the completion of the study and analysis.
Summary
In this chapter, the research study design and data collection methods for this
study are explained. The researcher provides details of the study and sample population,
instrumentation used to collect data, data analysis and procedural steps taken to protect
human subjects participating in the research study. Chapter four will provide detail of the
data analysis.
44
Chapter 4
DATA ANALYSIS
Introduction
This chapter examines the results of the research study. The purpose of this study
was to explore mental health providers’ perceptions and beliefs about American Veterans
from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who are
reporting symptoms of post-traumatic stress disorder, including treatment approaches to
best serve this population.
The participants were asked to answer nine questions about their perceptions and
beliefs regarding post-traumatic stress disorder and Veterans serving in the Operation
Enduring Freedom and Operation Iraqi Freedom wars. Participants were coded by a
color in order to protect anonymity. Three main themes emerged through the data which
were: 1) technology and environment role in the manifestation of post-traumatic stress
disorder symptoms, 2) how post-traumatic stress disorder may relate to increased acts of
violence in Veterans, and 3) the use of multi-modal treatment approaches and practitioner
perceived barriers to treatment.
This chapter will describe demographic information about the study participants.
Following, the responses to some of the interview questions will be described. Lastly,
each of the three themes will be discussed by utilizing quotes from the participant
responses to illustrate the themes. To ensure the identity of the participants, all study
participants were given a pseudo name.
45
Participant Demographics
All participants were adults who have a Masters of Social Work degree or are
registered as Licensed Clinical Social Workers. Seven out of ten respondents are female
and the other three respondents are male. Of the clinicians interviewed for this study,
eight reported their ethnicity as Caucasian. The other two clinicians reported their
ethnicity as bi-racial; African American and Caucasian. Experience with working with
Veterans who experience symptoms of post-traumatic stress disorder ranged from less
than one year to fifteen years.
Impact of Technology and Environment
The researcher asked participants to identify common symptoms of post-traumatic
stress disorder reported by OEF and OIF Veterans, the factors in their opinion
contributing to a high number of OEF and OIF Veterans returning from war diagnosed
with post-traumatic stress disorder, and in general what they think is different about the
manifestation of post-traumatic stress disorder in the current wars as compared to past
wars. One hundred percent of the responses mimicked what was found in the literature
review regarding specific symptoms of post-traumatic stress disorder in a war zone
including harsh elements, inconsistencies regarding “enemies,” and a heightened state of
stress for long periods of time (Litz, 2007).
Upon being asked, “What do you think are the reasons contributing to the high
number of Veterans returning from Operation Iraqi Freedom and Operation Enduring
Freedom with symptoms of PTSD?,” participant Timothy stated:
46
Well, it’s the exposure to trauma itself, combat, and multiple deployments. I think
the multiple deployments are important because if someone is traumatized they can
maybe come back stateside, they are still military, they have a job to do, their mind is
on work and not on healing…The more exposure one has the coping skills start to
break down. Definitely the multiple exposures…The use of IEDs {improvised
explosive device}, the type of weapons they’re being exposed to; [it is] often very
surprising; sudden. The damage is pretty significant. There’s also a lot of combat
trauma that’s taking place around civilians that’s not something particularly
something someone trains for. You may be trained to combat with the enemy and
defend yourself; you get into some of these difficult situations where like civilians
are hurt, or [soldiers] put in a position between defending themselves or their fellow
troops or take the life of someone who could be a civilian, or you’re not sure could
be an enemy combatant. That’s particularly difficult in a lot of cases because they
come back and have to second guess themselves and had to fight against
nontraditional enemies.
Timothy highlights how unknown the situation can be for soldiers given the use of
More technologically advanced weaponry, and a less defined “enemy”. Participant Greta
shared similar feeling in part of her response stating, “New technologies and advanced
medicine…under prepared for what they are seeing. Although how do you prepare
someone to see death?” Every participant noted the advancement or weaponry and the
overall experience of war in their answer. In the study conducted by Ramchand et al.
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(2010), their finding supports that length of deployments, multiple deployments and
intensity of combat experienced contributed to developing symptoms of post-traumatic
stress disorder.
There have also been technology advancements in the way that people
communicate with one another, particularly over social media. These platforms were not
available in previous wars, and soldiers were unable to communicate with loved ones in
real time most often. Greenberg and Dratel (2005) found that concerns about life and
family disruptions contributed to the high stress level experienced by Operation Enduring
Freedom and Operation Iraqi war Veterans and can play a role in the symptomology of
post-traumatic stress disorder. An interesting response came from participant Faye
whose answer focused beyond war caused reasoning for the symptom manifestation:
I think that some of the nature of the wars themselves, unpredictable IED explosions,
both vehicle (car IED, bus IED, etc.) bound and human bound, multiple deployments.
I think that part of the .. economy right now in the last seven years; because people
need employment they are choosing military service and that can lead to multiple
deployments and PTSD. The higher exposure to traumatic events there’s a higher
rate of having PTSD. Often there’s childhood trauma…along with financial stressors.
I think more women are serving and women are at a higher rate of having PTSD than
men just overall in population.
Faye was the only participant to mention the fact that women are more involved
in these current wars than past wars like World War II or the Vietnam War. This was
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prosed as an area of more research in the literature review. While not specifically
focused on female Veterans, a study found that women who re-experience trauma from
someone else’s experience can develop mental hardships and psychological distress
associated with post-traumatic stress disorder (Hamilton, Goff, Crow, & Reisberg, 2009).
Responses also contained mention of criteria for post-traumatic stress disorder as listed in
the DSM-IV-R (American Psychological Association, 2001) such as “seeing the trauma
of fellow soldiers killed/injured and/or themselves being injured while deployed” as
reported by participant Kim.
Chaumba and Bride (2010) explore the gender differences in the underdiagnoses
of women veterans with posttraumatic stress disorder. This article suggests that women
service members experience three types of trauma while serving in the military including
sexual, combat, and environmentally induced. While women are twice as likely to be
affected by PTSD it goes highly unrecognized due to lack of experience by practitioners
who often fail to ask women about military experience (Chaumba & Bride, 2010). Much
more focus has traditionally been placed on the diagnosis and treatment of men in the
military than on women service members. Due to the lack of diagnosis of women it may
be suggested that more research needs to be done in treating female Veterans with PTSD
because they may not respond to treatment the same way as men.
Post-traumatic Stress Disorder and Acts of Violence
There has been some research studies focused on aggression as a possible way to
regulate emotions linked with high amounts of stress. In one research study it was found
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that experiencing symptoms of post-traumatic stress disorder can produce a severe
disruption in emotional experience, and this could explain why a person diagnose with
post-traumatic stress disorder could act out in a violent manner in order to experience
emotional regulation (Tull, Jakupcak, Paulson, & Gratz, 2007). The media has had a role
in reporting situation in where Veterans displayed an act of anger, and it seems like the
public could link it to post-traumatic stress disorder as there is already a stigma that exists
around PTSD. The researcher wanted to see if there might be validity to the linkage from
a clinical standpoint and therefore asked participants, “What symptoms of PTSD are most
commonly being reported by OEF and OIF Veterans you have worked with?” and “Of
the symptoms reported…which ones do you believe are most likely to increase potential
for acts of violence?”.
One half of the participants listed sleeping problems or insomnia as one of the
main symptoms reported by Veterans suffering from post-traumatic stress disorder.
Other reported symptoms were: hyper vigilance, flashbacks, intrusive thoughts/images,
exaggerated startle response irritability, anger, avoidance of stimuli, and anger. Faye
described anger as “fly[ing] off the handle quickly, lack of patience.” Participant Peggy
described how symptoms affect Veterans she currently runs a group with:
As far as symptoms; anger, hyper arousal, low frustration tolerance, and a really
difficult time to tolerate things like driving and coming to appointments they get
frustrated. Or they see a staff member that parks in a patient spot. I have a group
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right now that their personal goal is to write down license plates and give them to the
police department.
It might seem like trivial things to someone not suffering from symptoms of posttraumatic stress disorder, but for Veterans diagnosed with post-traumatic stress disorder it
is difficult to acclimate back to the civilian lifestyle. Flashbacks of events that happened
during war can be so intrusive to Veterans that it feels like they are back in the war as
noted by Greta. Timothy also reports that crowds and not wanting to go places
(avoidance) are also frequently reported by Veterans he works with because “things are
unpredictable: there’s strangers, can’t control the outcomes”.
Participants responded rapidly without too much thought when asked what
symptoms of PTSD are experiences by Veterans, however when asked to link these
symptoms to propensity for acts of violence, the question was received as uncomfortable
by participants as displayed by their change in posture, hesitance to answer, and lingering
thoughts. Five respondents freely answered the question while the other five struggled
with answering. Participant Emery provided the following response when asked how
PTSD is linked to increased acts of violence:
Just the symptoms of PTSD? [pause] I think what’s difficult about that question is
that it’s really it’s not as if any of those symptoms specifically from PTSD would
likely increase the violent acts or potential for violence however it’s the peoples’
personalities in combination with the symptoms and their severity that create the
perfect storm for violent acts. So I’m not really sure how I would answer that
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question but I think…I really think lack of sleep and the insomnia takes an incredible
toll on Veterans…on anyone!
Participant Eddie struggled with the question as well but provided the following
response:
Um, from the previous question I’d say loss of concentration. Um that’s a hard one.
Of the PTSD symptoms? Not co-occurring diagnoses? I think the anger. They just
go into rage really quickly, the lack of sleep. The avoidance plays out in that, their
lives get really restrictive…ends up being very isolating…And I think if you’re
mixing drugs or alcohol, just seems to be a common way of avoiding symptoms.
That definitely does not help the anger; that it contributes to a lot of some of the
violent acting act, you know?
Of the participants that struggled with the question about violence, Timothy
showed the most internal struggle over answering the questions. It seemed to the
presenter that some participants did not want to make a link between post-traumatic stress
disorder and acts of violence; however, each participant provided an answer of how the
two ideas were linked. No participant stated that the two topics were mutually exclusive.
Timothy’s response highlights his opinion on how the public and media see posttraumatic stress disorder:
Well, that’s kind of hard, because I don’t necessarily associate PTSD with violence
but a lot of people in the public do when they think of PTSD they think of violence
because that’s what they hear about. I had a discussion with a group today because
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there’s several recent incidents that have come to the attention to the public, and of
course they associate PTSD with being violent…Probably the irritability and anger
are the biggest symptoms. So if somebody’s really feeling that anxious arousal,
feeling that anger, that’s going to be associated with violence if you kind of lose
control. Again for me, I don’t associate PTSD violence…I think sometimes it’s
misunderstood or misconstrued.
It is not known whether Veterans that conduct a violent act are having a conscious
acting out behavior. According to planned behavior theory, human behavior is guided by
three factors: (1) beliefs about likely consequences of behavior, (2) beliefs held regarding
the normative expectations of others, and (3) beliefs about the presence of factors that
help or hinder the performance of a behavior (Ajzen, 1991). The question is whether the
violent act is committed as an emotion regulation or whether Veterans are aware of the
act. The research does not provide explanation of violent events as believed through the
eyes of the person committing the act.
Planned behavior theory believes the notion that beliefs about a behavior and the
decision to engage in said behavior are linked (Stecker, Fortney, Hamilton, & Ajzen,
2007). Assuming this theory is accurate in describing behavior, Veterans who act out in
a violent manner may view the act as a favorable way to release heightened emotions
which makes them more favorable to act out in such a manner. If they do not see the
violent behavior as a negative outburst they could be more likely to engage in the
behavior, especially if they have a history of responding to uncomfortable stimuli in this
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manner prior to being diagnosed with post-traumatic stress disorder. Conversely, the
theory suggests that a Veteran who views violently acting out as a negative behavior will
be less likely to commit a violent act. This may explain why there is not a concrete link
that this study found to exist between symptoms of post-traumatic stress disorder and acts
of violence.
For the purpose of this research study, the theme considered for these questions is
that there is a perceived connection between post-traumatic stress disorder and acts of
violence; however more research would need to be conducted to see what factors would
contribute to that hypothesis.
Multi-Modal Treatment Approaches and Barriers to Treatment
As stated in the literature review, there a multiple treatment approaches utilized in
treating post-traumatic stress disorder aimed at treating the estimated fifteen percent of
OIF and OEF Veterans diagnosed (Hoge et al., 2004). The most utilized approaches in
the Veterans Administration are cognitive behavioral emphasis (Elhers & Clark, 2000).
Eye Movement Desensitization and Reprocessing is noted in the literature for being
successful at diminishing symptoms of post-traumatic stress disorder yet respondent
Peggy stated, “most VA…the government’s not real excited about [EMDR] because it’s
kind of a form of hypnosis and they don’t want leakage coming out that’s uncontrolled
from the Vets or anything.”
Of the two respondents that mentioned EMDR as a treatment approach, only Kim
chose it as a main practice approach due to “effectiveness without re-traumatization”.
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Eye movement desensitization and reprocessing therapy involves having clients recall
traumatic events while focusing on a rapidly moving object (Garske, 2011). As for the
rest of the respondents, the following treatment approaches were named: 1) cognitive
processing therapy, 2) stress inoculation therapy, 3) medication in conjunction with
psychotherapy, 4) psychoeducational skills groups, 5) meditation and grounding
techniques, 6) therapeutic alliance, 7) narrative therapy, and 8) meridian tapping. While
the majority of these approaches are evidenced based interventions, it is noted by the
researcher that the other techniques are more experimental (meditation and meridian
tapping) which shows that there is a variation of services depending on the clinician
which you are working. It is thought that meridian tapping may produce the same type
of effects as eye movement desensitization and reprocessing (Spates et al., 2009). Peggy
gives explanation of how stress inoculation can help treat Veterans in conjunction with
cognitive processing therapy:
The stress inoculation therapy is a way for them to start talking about the symptoms
without having to talk about the trauma specifically. Stress inoculation is actually an
old therapy. It’s been utilized for years for phobias. It’s kind of a gradual kind of
like…say a Vet doesn’t want to be in crowds. So we might start by me sitting with
him in primary care, then we go to a gradual process to get more and more exposed to
things that caused a lot of anxiety. Cognitive processing therapy is combining stress
inoculation therapy and then what you are talking about.
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Cognitive processing therapy asks clients to challenge faulty assumptions and
self-statements they are holding on to in order to modify overgeneralized beliefs (Monson
et al., 2006). The researchers found that this technique help successful outcomes for both
men and women. The ultimate goal for this therapeutic approach is to change the thought
patters regarding the trauma in order to influence client behavior (Elhers & Clark, 2000).
While only one respondent mentioned the use of pharmacotherapy for treating symptoms
of post-traumatic stress disorder, the use of psychotropic medication is a treatment option
widely utilized in the mental health field. Antidepressants in the form of serotonin
reuptake inhibitors have been beneficial in treating the anxiety type symptoms connected
with the description of post-traumatic stress disorder (Londberg et al., 2001).
Participant Agatha supports group therapy and psychoeducational groups in
conjunction with individualized therapy because “it gives an opportunity for Veterans to
see they are not alone and build a network of peers for support.” Sixty percent of the
respondents identified peer groups as being a beneficial therapeutic intervention.
Timothy identified what he thinks treatment needs to target in the following passage:
What we know about treatment is that you really have to get at two different main
components of what keeps PTSD alive. The number one is avoidance. So when
someone’s exposed to trauma one way they try to cope with that or heal themselves is
to stay away from other traumas…What they’re trying to do is like emotionally heal,
they’re trying to keep themselves safe. They feel this relief by staying away from
things that cause them trauma, but it kind of reinforces this idea that the outside world
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is dangerous…The other part is some of the beliefs people develop as a result of
being traumatized…Things can get better. For some folks that’s hard to believe
because they’ve had 40 years of this unshakeable belief of how they have to live.
When they begin to see different results they start to wait for something to change
and go back to the way it was…
Timothy articulates what the theme between all of the respondents was in
response to best treatment approaches. The best approach targets the symptoms
experienced by the Veteran. When the researcher asked respondents to explain why they
chose their particular approach to use, eighty percent stated that it was because that is the
technique they were trained or familiar with working. This correlates with implications
for social work in line with the ethical standard of practice competency (National
Association of Social Workers, 2001).
There was no question conducted in the interview that asked researches to
describe what they believed were barriers to treatment for OIF and OEF Veterans seeking
treatment for post-traumatic stress disorder. According to recent measurements, only
approximately one fourth to one half of service members willing to acknowledge
experiencing mental health symptoms will see out services (Hoge et al., 2006).
According to the research, numerous barriers exist for Veterans including but not limited
to being perceived as weak, preferring to take care of problems on their own, and stigma
of having a mental health disorder (Hoge et al., 2004). After research was conducted, the
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author noticed a theme of perceived barriers of treatment running throughout answers of
multiple questions. Emery states,
I think one of the most challenging issues facing our Veterans going home is the
stigma and the misinformation in society about what PTSD is, because any person
going through any situation that differs from the mainstream will have a reclamation
process that they have to go through…I couldn’t imagine going through a traumatic
experience where every day was a life threatening situation that I have to deal with
and then acclimate back into a society that doesn’t understand…Just as with any
psychiatric disability, the label associated with being broken or not right is very hard
to deal with.
Personal factors for Veterans of wanting to solve the problem for themselves or believing
it will go away in time are greater barriers to care than logistical issues like accessing
appointment time, and it was also reported by female Veterans that lack of women
specific services is a huge barrier to them seeking out mental health treatment (Vogt et
al., 2006). Faye also speaks to the stigma associated with Veterans diagnosed with posttraumatic stress order. Her thoughts were as follows:
Despite efforts of reducing stigma we still have a lot of no show rates or they’ll come
once and that’s it. There seems to be lots of barriers. They don’t want to be living
with PTSD but there’s a lot going on in their lives. They’re going to school or
working or have families or are trying to start families; meet people. The last thing
they want to do is come to therapy, even though some of them are only twelve weeks
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long. I mean three months. So that’s what comes to mind…still trying to figure that
out.
It is also noted by participant Jim that not following through with treatment is a barrier
for Veterans seeking help. One important thing to note is that these barriers are attributed
to current war Veterans but past war Veterans as well. Eddie has observed in his work
with Veterans that
One thing that’s really common in some groups or some individuals you’ll hear form
the Vietnam Veterans some resentment that these services are available for the
younger guys and some acknowledgement that they paved the way for the younger
guys to get the services that they’re getting.
This barrier could be present for both older Veterans and recent Veterans in that maybe
some feel that they do not deserve treatment or perhaps feel that treatment will give them
stigma due to feelings about how services are available now and were not before. This
research reinforces that barriers do exist for Veterans seeking treatment as outlined in the
literature review. Ways of overcoming barriers to treatment may consist of looking at the
larger system of care to see where improvements can be made in order to meet the needs
of Veterans using a systems theory framework. The Veterans Administration can explore
how the multiple systems Operation Enduring Freedom and Operation Iraqi Freedom
Veterans communicate with one another in order to improve efficiency, and how the
systems can improve in order to increase access and variety to services offered to
Veterans.
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Mental health practitioners can assist Veterans in overcoming barriers to seeking
out mental health treatment by being knowledgeable about how to navigate through the
multiple systems of care that Veterans are involved with. Competency in clinical
interventions used to treat symptoms of post-traumatic stress disorder, and a willingness
to collaborate with the Veteran who is seeking services has shown to decrease barriers to
care (Adler, Kwon, & Singer, 2005). Continued dialogue between service providers and
Veterans will continue to improve the systems of care.
Summary
This chapter analyzed and discussed the data derived from the research study.
Chapter five describes the study conclusions and recommendations. The chapter also
discusses implications for social work practice.
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Chapter 5
CONCLUSIONS AND RECOMMENDATIONS
Introduction
This chapter will discuss the conclusions reached in this project. The four themes
that emerged during the interviews will be discussed as they relate to each other, and to
mental health treatment of post-traumatic stress disorder for Operating Enduring Freedom
and Operation Iraqi Freedom Veterans. The chapter will also discuss recommendations
for future studies, examine limitations of this study, and outline implications of the study
for social work and practice.
Conclusions
This study asked the research question: What are mental health providers’
perceptions of post-traumatic stress disorder and beliefs regarding best treatment
approaches for American Veterans who served or are serving in the Operation Iraqi
Freedom and Operation Enduring Freedom wars? As participants answered the study
questions the first theme emerged. Providers felt that there are numerous reasons for the
high diagnoses of Operation Enduring Freedom and Operation Iraqi Freedom war
Veterans. Most of the reasons fall under two categories which are technology
advancement and environment. In the wars being studied there has been a development
of war technology unseen in wars before. The use of improvised explosive devices has
added an additional level of uncertainty in warfare. Improvised explosive devices are
typically vehicle bound or person bound, and often soldiers can be caught unaware when
61
they are exploded. There are also new screening and recording devices that are utilized
in the wars which gives access to “replay” traumatic incidents which may increase the
likelihood of experiencing post-traumatic stress disorder symptoms.
Besides strides in modern warfare technology, there has been an increase of
technology that allows soldiers to keep in touch with people and elements of their lives
that was not possible in previous wars. Soldiers are able to connect with loved ones via
Facebook, Skype, and multiple other social media platforms that allow them to keep in
touch with their life while they’re away. However, this can have negative ramifications
especially if there are stressors in their home life that they would have otherwise been
unexposed to during their tours. An increase in stress may also exacerbate symptoms of
post-traumatic stress disorder.
Operation Iraqi Freedom and Operation Enduring Freedom take place in harsh
environments. Due to being in the desert, soldiers are exposed to high heat, wind,
unfamiliar terrain, and a variety or insects and animals. Also, there is a lack of personal
space and freedom when stationed. As noted by Killgore et al. (2008), traditional combat
events contribute to the manifestation of post-traumatic stress disorder including injury
during combat, inflicting injury or death upon someone else (enemy or civilian), and
handling body remains.
This research study found that practitioners will identify an underlying connection
between symptoms of post-traumatic stress disorder and a propensity for increased acts of
violence. While no participant confidently stated a connection between the two items,
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each participant provided a reason of why post-traumatic stress disorder can increase acts
of violence. Answers ranged from sleep deprivation and hypervigilance to anger as its
own measure for violence. From the answers provided and due to the fact that this was
not the main focus of the research study, outcomes regarding a connection between posttraumatic stress disorder and increased acts of violence was found by this researcher to be
inconclusive.
A variety of treatment approaches were suggested by participants in the study.
Treatment approaches included: cognitive processing therapy, prolonged exposure
therapy, stress inoculation therapy, psychoeducational groups, narrative therapy,
cognitive behavioral therapy, eye movement desensitization and reprocessing (EMDR),
and meridian tapping. Research states that cognitive processing therapy, prolonged
exposure and, EMDR are currently used to treat Veterans with post-traumatic stress
disorder ((Monson et al., 2006). Some participants also stated that they found peer
groups to be very helpful for Veterans diagnosed with post-traumatic stress disorder
because it allows them to make connections with others living similar experiences.
Participants noted that treatment approaches utilized depend on what symptoms
treatment seekers are experiencing and/or willingness to discuss actual trauma. For those
not yet ready to delve into their experience, stress inoculation therapy and group work
have been shown to be beneficial as noted by research participants that have used these
approaches. A few respondents also suggested areas where they believe treatment could
be improved including providing more mental health treatment to the families of the
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Veteran and working through barriers of care. This thought is in line with the finding
that numerous barriers of care exist for Veterans seeking services. Stigma of having a
mental health diagnosis continues to be a barrier for seeking treatment as reported by
research participants and the literature review. Also, one participant in specific
mentioned that Veterans coming back have many roles to maintain including having a
family, going to school, and maintaining employment. These factors make it even more
difficult for Veterans to find time to seek out mental health treatment.
Recommendations
The two areas where this study makes recommendations: future research and mental
health practitioner practice. The recommendations are presented below.
Future Research
Suggestions for future research include generating a larger and more diverse sample
including participants who serve Veterans without specifically working for the Veterans
Administration. With a larger sample, the results would be more accurate and have
greater generalization to the larger population. With a more diverse sample population,
biases derived from the Veterans Administration regulations for best treatment
approaches may be better avoided.
In addition, by collecting data from various target sites, experience and longevity in
the field would be more heavily weighted in the analysis and could add more insight to
the research question. This would allow for a broader potential to identify treatment
approaches that have proven to be beneficial from a practitioners stand point and not only
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according to the agency of employment. Interventions surrounding specific symptom
manifestation of post-traumatic stress disorder can be implemented to allow for greater
potential success with the findings of an expanded research study. Further research would
need to be completed to follow up with this suggestion. Lastly, the researcher suggests
that the relationship between post-traumatic stress disorder and potential for increased
acts of violence be explored as an independent research topic in order to gain more
information about the study.
Mental Health Practitioner Practice
This study suggests several recommendations for mental health practitioners
providing treatment to Operation Enduring Freedom and Operation Iraqi Freedom
Veterans. The first is to continue to learn and become competent in treatment approaches
that are currently utilized by the Veterans Administration in treating Veterans. The
research finds that on average practitioners use a cognitive processing therapy approach
or prolonged exposure approach as they are currently used by the Veterans
Administration and have attended trainings in those approaches. The second suggestion
is to maintain a willingness to learn about new treatment approaches that may be helpful
to Veterans seeking mental health treatment. Practitioners could utilize consumer
feedback in order to check if their practice is beneficial and meeting the target needs of
the Veteran seeking services.
Both of these recommendations are in accordance of the ethical principal
competence, as outlined in the National Association of Social Workers Code of Ethics
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(2001). In order to maintain competency social workers will strive to maintain
professional skills and increase practice skills to develop their practice base.
Practitioners will take to make sure that practice approaches are culturally relevant and an
appropriate match to the person that they are delivering services.
Limitations
The limitations of this study include the disadvantages of utilizing a qualitative
research approach. One of the limitations is the use of a small sample size. Results
obtained by using a small sample data are limited and less able to generalize to a larger
population. Data was collected from participants with vast differences in the amount of
experience working with Veterans which makes it even more difficult to make
generalizations about the sample population much less the study population. Another
limitation is that data was collected through use of self-report when can result in
responder bias. Though participants were assured that their responses were confidential,
some participants may not have felt comfortable responding honestly due to reporting
answers in their place of employment. In the analysis of data, researcher bias may have
played a role in how information was coded for meaning and patterns.
Implications for Social Work Practice and Policy
The implications of this study will benefit mental health practitioners serving
Veterans diagnosed with post-traumatic stress disorder as well as Veterans themselves by
ensuring that they will receive adequate treatment for their mental health needs. On a
micro level, practitioners will be able to select a practice approach that best fits the needs
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of the Veteran they are working with and tailor treatment to their unique needs. This will
help the Veteran seeking treatment to manage symptoms of post-traumatic stress
disorder, and possibly encourage them to maintain their treatment. This study adds to the
dialogue regarding post-traumatic stress disorder and military Veterans. Veterans who
may possibly read this study might feel that they are being heard, and decide to speak
with their mental health clinicians and fellow peers about what would help them in
managing their symptoms of post-traumatic stress disorder. On a mezzo level, this study
has implications for the Department of Defense and Veteran Administration on how to
meet the needs of Veterans serving in the Operation Enduring Freedom and Operation
Iraqi Freedom wars. Both organizations will benefit from knowing what practice
approaches practitioners utilize most often as well as feel are most beneficial to the
treatment population which can impact program structure.
On the macro level, this study will contribute to helping society to gain a better
understanding of how Veterans experience post-traumatic stress disorder and what
contributes to the onset. The study can open a dialogue regarding stigma of the mental
health label post-traumatic stress disorder, and how it effects the transition of Veterans
back into the community. Findings from the study may help to inform national policy
practice for treatment of post-traumatic stress disorder. Lastly, it is hoped that this study
will spark social workers into focusing on becoming competent in their practices in order
to reach and confidently serve Veterans diagnosed with post-traumatic stress disorder.
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Conclusion
The purpose of this study was to contribute to research focused on the manifestation
of post-traumatic stress disorder in Operation Enduring Freedom and Operation Iraqi
Freedom war Veterans. This study explored mental health treatment providers’
perceptions and beliefs regarding post-traumatic stress disorder in general, how posttraumatic stress disorder differs between the current wars and previous wars, and what
they believe to be the best practice approaches to treat Veterans experiencing symptoms
of post-traumatic stress disorder.
The research suggests that advancements in technology and aspects in the
environment contribute largely to the onset of post-traumatic stress disorder in OIF and
OEF Veterans. Analysis of the research found that a link between symptoms of posttraumatic stress disorder and an increase for acts of violence that may exist; however at
this time the data in inconclusive. Participants responded with a range of practice
approaches they believed to be most successful at treating Veterans diagnosed with posttraumatic stress disorder. Cognitive processing therapy, prolonged exposure, and
psychoeducational groups were utilized most often due to being approved as treatment
approaches by the Veterans Administration and practitioner familiarity or training in
practice approaches. Lastly, numerous barriers to treatment were found to exist with
stigma related to mental health diagnosis being the number one cause for not seeking
treatment, and other life stressors being secondary. There is a need for continued
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research in order to connect the findings of this research project to the larger study
population.
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APPENDIX A
Sacramento State IRB Approval
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
DIVISION OF SOCIAL WORK
TO: Ann-Alecia Brewer
19, 2013
DATE: December
FROM: Committee for the Protection of Human Subjects
RE: YOUR HUMAN SUBJECTS APPLICATION – CONTINUING REVIEW
REQUEST
We are writing on behalf of the Committee for the Protection of Human Subjects
from the Division of Social Work. You have requested continuing review for one
year, in order to retain and work on your data.
We have granted your continuing review. Your proposed study, “Provider's
Perceptions and Treatment Approaches for American Veterans Reporting
Symptoms of Post-Traumatic Stress Disorder”, human subjects protocol number
12-13-048 expires one year from this date.
Please use your protocol number in all official correspondence and written
materials relative to your study. Approval carries with it the obligation to inform
the Committee promptly should an adverse reaction occur, and that you will make
no modification to the protocol without prior approval from the Committee.
The committee wishes you the best in your research.
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Professors:
Maria Dinis
Jude Antonyappan
Francis Yuen
Serge Lee
Kisun Nam
Dale Russell
cc: Dinis
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APPENDIX B
Consent to Participate in Research
You are invited to participate in a research study that will be conducted by Ann-Alecia
Brewer, a graduate student at California State University, Sacramento. This study will
explore providers’ beliefs/perceptions and treatment approaches for American Operation
Enduring Freedom and Operation Iraqi Freedom Veterans reporting
experiences/symptoms of PTSD.
Procedures:
After reviewing this form and agreeing to participate you will be given the opportunity to
set up an interview time convenient for you. The interview should take approximately
twenty to thirty minutes and will be audio taped. The tape will be transcribed and then
destroyed.
As a participant in the interview you can decide at any point to not answer any specific
question or to stop the interview at any time.
Risks:
The questions asked in this study are about your professional views and knowledge. As a
result there are no foreseen risks associated with the nature of this study.
Benefits:
By being part of this study you may gain further insight into your clinical practice
working with Veterans diagnosed with PTSD. In addition this research may help others
to further understand PTSD. This information may be useful in providing more effective
mental health treatment services to Veterans.
Confidentiality:
All information will be kept confidential and every effort will be made to protect your
privacy. Your responses on the audiotape will be kept confidential. Information you
provide on the consent form will be stored separately in a locked file box from the
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audiotapes in a secure location. All audiotapes will be transcribed by the researcher. The
researcher’s thesis advisor will have access to the transcriptions for the duration of the
project. The final research report will not include any identifying information. All of the
data will be destroyed upon completion of the project.
Compensation:
You will receive a $10 gift card for your participation in this project.
Rights to withdraw:
If you decide to participate in this interview, you can withdraw at any point. During the
interview you can elect not to answer any specific question.
Consent to Participate as a Research Subject
I have read the descriptive information on the Research Participation cover letter.
I understand that my participation is completely voluntary. My signature indicates that I
have received a copy of the Research Participation cover letter and I agree to participate
in the study.
I ____________________________________ agree to participate in the study.
Signature: ____________________________________
Date: ______________
I ____________________________________ also agree to be audio taped.
73
Signature: ____________________________________
Date: _____________
If you have any questions you may contact the researcher, Ann-Alecia Brewer.
Or, if you need further information, you may contact my thesis advisor:
Maria Dinis, Ph.D., MSW
c/o California State University, Sacramento
916-278-7161
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APPENDIX C
PTSD and Veterans Practitioner Survey
What is your gender?
Male
Female
Transgender
What is your ethnicity? (check all that apply): [ ] African American, [ ] Asian, [ ] Hispanic/Latino,
[ ] Caucasian, [ ] Other: Please Describe:_____________________________________________
What is the highest educational degree you have
completed?______________________________________
Professional Area: (circle appropriate response)
What is your professional area of expertise? Psychology, Social Work, Counseling,
Nursing, Medicine, Other (please describe):______________
1. How long have you worked with United States Military Veterans who experience symptoms
of post-traumatic stress disorder?
2. In your opinion, what do you think are the reasons contributing to the high number of
Veteran’s returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
with symptoms of PTSD?
3. What symptoms are of PTSD are most commonly being reported by OEF and OIF Veterans you
have worked with?
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4. Of the symptoms reported by OEF and OIF Veterans, which ones do you believe are most
likely to increase potential for acts of violence?
5. In general, what do you think is different about PTSD in the most recent wars as compared to
previous wars?
6. What interventions, treatments, or techniques have you found most helpful in treating
Veterans experiencing PTSD?
7. If you had to select just one therapeutic approach/method to treat Veterans experiencing
PTSD, which approach/method would you pick?
8. Why did you select this approach/method?
9. Any other comments or suggestions?
76
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