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Background: It has been suggested that current frontline posttraumatic stress disorder (PTSD) treatments are not effective for the treatment of moral injury and that individuals who have experienced morally injurious events may respond differently to treatment than those who have not. However, these claims have yet to be empirically tested. Objective: This study evaluated the rates of morally injurious event exposure and morally injurious index trauma and their impact on PTSD (PCL-5) and depression symptom (PHQ-9) reductions during intensive PTSD treatment. Method: Data from 161 USA military combat service members and veterans (91.3% male; mean age = 39.94 years) who participated in a 3-week Cognitive Processing Therapy (CPT)-based intensive PTSD treatment programme (ITP) was utilized. Morally injurious event exposure was established via the Moral Injury Event Scale (MIES). Index traumas were also coded by the treating clinician. Linear mixed effects regression analyses were conducted to examine if differences in average effects or trends over the course of treatment existed between veterans with morally injurious event exposure or index trauma and those without. Results: Rates of morally injurious event exposure in this treatment sample were high (59.0%-75.2%). Morally injurious event exposure and the type of index trauma did not predict changes in symptom outcomes from the ITP and veterans reported large reductions in PTSD (d = 1.35-1.96) and depression symptoms (d = 0.95-1.24) from pre- to post-treatment. Non-inferiority analyses also demonstrated equivalence across those with and without morally injurious event exposure and index events. There were no significant gender differences. Conclusions: The present study suggests that PTSD and depression in military veterans with morally injurious event exposure histories may be successfully treated via a 3-week CPT-based ITP.

ObjectiveThe purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD).MethodThe present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment.ResultsOn average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program.ConclusionsThe present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Although evidence-based treatments for posttraumatic stress disorder (PTSD), such as Cognitive Processing Therapy (CPT), have been developed and widely disseminated, the rate of veterans engaging in and completing these therapies is low. Alternative methods of delivery may be needed to help overcome key barriers to treatment. Delivering evidence-based therapies intensively may address practical barriers to treatment attendance as well as problems with avoidance. This report details the case of a combat veteran who received 10 sessions of Cognitive Processing Therapy delivered twice per day over a single, five-day work week (CPT-5). Post-treatment, the veteran reported large and clinically meaningful decreases in PTSD and depression symptom severity as well as in guilt cognitions, which is a purported mechanism of successful treatment. These effects persisted six weeks after treatment ended. Despite the intensive nature of the treatment, the veteran found CPT-5 tolerable and could cite many benefits to completing therapy in one work week. In conclusion, CPT-5 holds promise as a way to efficiently deliver an evidence-based therapy that is both clinically effective and acceptable to patients, although more rigorous clinical trials are needed to test this treatment delivery format.

ObjectiveMoral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied.MethodWe conducted semistructured interviews with eight veterans who reported experiencing morally injurious events during war zone deployments.ResultsUsing narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up.ConclusionThe findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

BackgroundIntensive delivery of evidence-based treatment for posttraumatic stress disorder (PTSD) is becoming increasingly popular for overcoming barriers to treatment for veterans. Understanding how and for whom these intensive treatments work is critical for optimizing their dissemination. The goals of the current study were to evaluate patterns of PTSD and depression symptom change over the course of a 3-week cohort-based intensive outpatient program (IOP) for veterans with PTSD, examine changes in posttraumatic cognitions as a predictor of treatment response, and determine whether patterns of treatment outcome or predictors of treatment outcome differed by sex and cohort type (combat versus military sexual trauma [MST]).MethodOne-hundred ninety-one veterans (19 cohorts: 12 combat-PTSD cohorts, 7 MST-PTSD cohorts) completed a 3-week intensive outpatient program for PTSD comprised of daily group and individual Cognitive Processing Therapy (CPT), mindfulness, yoga, and psychoeducation. Measures of PTSD symptoms, depression symptoms, and posttraumatic cognitions were collected before the intervention, after the intervention, and approximately every other day during the intervention.ResultsPre-post analyses for completers (N = 176; 92.1% of sample) revealed large reductions in PTSD (d = 1.12 for past month symptoms and d = 1.40 for past week symptoms) and depression symptoms (d = 1.04 for past 2 weeks). Combat cohorts saw a greater reduction in PTSD symptoms over time relative to MST cohorts. Reduction in posttraumatic cognitions over time significantly predicted decreases in PTSD and depression symptom scores, which remained robust to adjustment for autocorrelation.ConclusionIntensive treatment programs are a promising approach for delivering evidence-based interventions to produce rapid treatment response and high rates of retention. Reductions in posttraumatic cognitions appear to be an important predictor of response to intensive treatment. Further research is needed to explore differences in intensive treatment response for veterans with combat exposure versus MST.

With approximately 20 veteran suicide deaths per day, suicidal ideation (SI) among veterans is an important concern. Posttraumatic stress disorder (PTSD) is associated with SI among veterans, yet mechanisms of this relationship remain unclear. Negative posttraumatic cognitions contribute to the development and maintenance of PTSD, yet no studies have prospectively examined the relationship between posttraumatic cognitions and SI. Veterans (N = 177; 66% Male) participating in a 3-week intensive outpatient program for PTSD completed assessments of PTSD severity, depressive symptoms, SI, and posttraumatic cognitions. Negative posttraumatic cognitions about the self significantly predicted SI at posttreatment, controlling for pretreatment levels of SI, depression, and PTSD symptom severity. Self-blame and negative posttraumatic cognitions about others/world did not predict SI prospectively. Negative posttraumatic cognitions about the self appear to be an important factor in the manifestation of SI among veterans with PTSD and should be monitored as a potential indicator of suicide risk.

BackgroundUnique aspects of military sexual trauma (MST) may result in specific maladaptive cognitions among survivors. Understanding which posttraumatic cognitions are particularly strong among MST survivors could help clinicians target and improve treatment for these individuals. This study explored the impact of experiencing MST on posttraumatic cognitions among veterans with posttraumatic stress disorder (PTSD).MethodsVeterans enrolled in an Intensive Outpatient Program for PTSD (N = 226) were assessed for MST, PTSD severity, depression severity, and posttraumatic cognitions as part of a standard clinical intake. Multivariate analyses examined differences in posttraumatic cognitions between veterans who did and did not experience MST.ResultsMST survivors (n = 88) endorsed significantly stronger posttraumatic cognitions related to self-blame compared to non-MST counterparts (n = 138), even when accounting for current symptom severity. Specifically, MST predicted the following cognitions: "The event happened to me because of the sort of person I am," "Somebody else would have stopped the event from happening," "Somebody else would not have gotten into this situation," and "There is something about me that made the event happen," after controlling for severity of PTSD and depression.LimitationsStudy population was a treatment-seeking sample of veterans diagnosed with PTSD from a non-VA clinic. Veterans in MST group endorsed either sexual harassment, sexual assault, or both. Sample size of males who endorsed MST (n = 21) may be too small to generalize to all males.ConclusionsBeliefs related to self-blame may be important treatment targets for MST survivors.

Moral injury refers to acts of commission or omission that violate individuals' moral or ethical standards. Morally injurious events are often synonymous with psychological trauma, especially in combat situations; thus, morally injurious events are often implicated in the development of PTSD for military service members and veterans. Although Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have been well-established as effective treatments for veterans who are struggling with posttraumatic stress disorder (PTSD), it has been suggested that these two evidence-based therapies may not be sufficient for treating veterans whose PTSD resulted from morally injurious events. The purpose of this manuscript is to detail how the underlying theories of PE and CPT can account for moral-injury based PTSD and to describe two case examples of veterans with PTSD stemming from morally injurious events who were successfully treated with PE and CPT. The manuscript concludes with a summary of challenges that clinicians may face when treating veterans with PTSD resulting from moral injury using either PE or CPT.

Exposure to potentially morally injurious events has been shown to be associated with posttraumatic stress disorder (PTSD) and depression symptoms in military personnel. Few studies have examined factors that help to explain how potentially morally injurious events may contribute to the development of trauma-related psychopathology. Negative posttrauma cognitions are thought to play a role in the etiology of PTSD and depression following trauma; however, it is unclear whether more global beliefs about the self, others, and world play a role in the development of PTSD and depression due to morally injurious events. Using structural equation modeling, we tested whether morally injurious experiences were indirectly related to trauma-related psychopathology (PTSD and depression) through negative posttrauma cognitions in a sample of veterans seeking treatment for PTSD. An indirect effects only model best fit the data and showed that morally injurious experiences, specifically perceived transgressions by oneself and perceived betrayal, were indirectly associated with trauma-related psychopathology through negative posttrauma cognitions, β = .17; 95% CI [.04, .31] and β = .25; 95% CI [.11, .41], respectively. Our findings suggest that negative posttrauma cognitions may be an important mechanism linking exposure to morally injurious events and trauma-related psychopathology.

Moral injury refers to a set of reactions to acts of perpetration or commission that violate an individual's deeply held beliefs and moral values. Although there is consensus that military service increases exposure to morally injurious events, there is no clear definition on what events do and do not constitute moral injury, which makes drawing firm conclusions regarding the prevalence of moral injury among military populations difficult. Exposure to morally injurious events places individuals at a greater risk for a range of poor mental health outcomes, which may be mediated by negative posttraumatic cognitions. Therefore, treatments that emphasize restructuring such cognitions are likely to be effective in treating the effects of moral injury, though data are lacking. In this article, we provide an overview of the key scientific findings regarding moral injury and highlight areas where future research is needed. Potential challenges in treating the negative sequelae of moral injury are also discussed.

Objective: The current study examined prospective, bidirectional relationships between 3 measures of spirituality (Daily Spiritual Experiences, Positive Religious Coping, and Negative Religious Coping) and frequency of heavy episodic drinking. Participants: Three hundred ninety-one students attending a large, public university in the Midwest. Methods: Electronic surveys assessing predictors of college alcohol use were sent to participants in the winter of their freshman and sophomore years. Structural equation modeling was used to analyze data. Results: A latent factor comprised of Daily Spiritual Experiences and Positive Religious Coping (ie, "positive spirituality") was negatively related to future frequency of heavy episodic drinking. Negative Religious Coping was unrelated to heavy episodic drinking. Additionally, heavy episodic drinking did not prospectively predict any measures of spirituality. Conclusions: Data are supportive of continued efforts to integrate positive spirituality into interventions for collegiate heavy episodic drinking.

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Objective: Using a framework informed by problem behavior theory, the authors examined differential relationships between religiosity and the frequency of cigarette and waterpipe tobacco smoking. Participants: Six hundred fourteen individuals beginning their freshman year at a large, public, midwestern university. Methods: Paper-and-pencil surveys were administered to students who attended freshman orientation. Electronic surveys were sent to students who did not attend orientation. Results: Although a latent, generalized religiosity factor was negatively associated with frequency of cigarette smoking, there was no such relationship for frequency of waterpipe use. Conclusions: Conceptualizing waterpipe tobacco smoking in terms of problem behavior theory may be inappropriate, given its lack of association with religiosity. These results may reflect the perception that waterpipe use is a more socially acceptable form of tobacco use that is less harmful to health than cigarette smoking, despite medical evidence to the contrary. Implications for prevention and intervention are discussed.

Although cognitive-behavioral therapy (CBT) is considered a treatment of choice for a variety of mental health conditions, many patients who could benefit either do not initiate treatment or they drop out early. Intensive models, in which CBT is delivered in multiple sessions per day over the course of 1 to 3 weeks, may be a promising model to address both underuse of CBT and premature dropout, but many questions remain about the clinical utility and feasibility of intensively delivered CBT. In this brief overview, we consider evidence that various models of intensively delivered CBT are associated with promising outcomes, low rates of patient drop out, and high rates of patient satisfaction. Directions for future research are also discussed Although cognitive-behavioral therapy (CBT) is considered a treatment of choice for a variety of mental health conditions, many patients who could benefit either do not initiate treatment or they drop out early. Intensive models, in which CBT is delivered in multiple sessions per day over the course of 1 to 3 weeks, may be a promising model to address both underuse of CBT and premature dropout, but many questions remain about the clinical utility and feasibility of intensively delivered CBT. In this brief overview, we consider evidence that various models of intensively delivered CBT are associated with promising outcomes, low rates of patient drop out, and high rates of patient satisfaction. Directions for future research are also discussed [[Psychiatr Ann. 2019;49(8):339–342.] [ABSTRACT FROM AUTHOR]

Individuals with posttraumatic stress disorder (PTSD) symptoms engage in greater rates of health care utilization. Existing literature is limited, however, because the number of visits to health care providers is exclusively used as an outcome. Low-income women ( N = 96) screening positive for PTSD symptoms ( n = 23; 23.9%) were compared to those who did not ( n = 73) on a range of health care utilization outcomes obtained through a chart review. Significant PTSD symptoms were associated with more complaints per visit, ordered labs, and prescribed medications-beyond the effects of age, depression symptoms, and chronic illness. Individuals with PTSD symptoms are a challenge to primary care as currently practiced. Collaboration with mental health professionals and specific primary care procedures to diagnose and treat PTSD are needed. [ABSTRACT FROM AUTHOR]

Objective: Chronic pain often co-occurs with posttraumatic stress disorder (PTSD). The mutual maintenance hypothesis proposes that there may be shared underlying mechanisms of symptoms of pain exacerbating PTSD, and vice versa. The association between PTSD and pain intensity remains understudied. To elucidate the relationship, the present study examined the temporality of changes in PTSD severity and pain intensity in veterans undergoing intensive PTSD treatment., Method: Data from 332 veterans undergoing intensive 2-week cognitive processing therapy- (CPT-) based treatment (ITP) with adjunctive components (i.e., mindfulness, art therapy). Random intercepts cross-lagged panel models (RI-CLPMs) were used to examine within-subjects relationships between pain intensity and PTSD severity over the course of the program., Results: Veterans experienced large PTSD severity reductions (Essg = 1.20; p < .001) and small pain severity reductions (Essg = 0.21; p < .001) over the course of treatment, despite pain not being a treatment target. RI-CLPMs revealed that PTSD severity significantly predicted subsequent pain severity. Results indicate the absence of a bidirectional relationship in that changes in pain intensity did not predict later PTSD severity improvement during the ITP. Time trends for both PTSD severity and pain intensity were generally consistent with respect to baseline demographic characteristics., Conclusion: Our findings support the mutual maintenance regarding the association between PTSD and pain intensity. Future research should investigate temporal associations in other evidence-based PTSD treatments and formats and evaluate the long-term impacts of PTSD treatment on pain intensity. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objective: Although there is mounting evidence that massed treatment for PTSD is both feasible and effective, many questions remain about the optimal length of intensive treatment programs (ITPs), as well as the role of adjunctive services, such as psychoeducation, mindfulness, and yoga. Our setting recently transitioned from a three-week ITP to a two-week program. Adjunctive services were reduced, but the amount of individual CPT between programs remained similar. The present study examined the effectiveness of a two-week ITP based on twice daily individual CPT sessions and evaluated the program's noninferiority to an established three-week ITP using a Bayesian analytical approach., Method: Bayesian linear mixed regression models were used to explore PTSD and depression changes over time, as well as predictors of change. Noninferiority of the two-week ITP to a three-week ITP was also established using a Bayes factor approach., Results: Results indicate that program participants change meaningfully in both PTSD and depression severity over the course of treatment, and that changes in posttraumatic cognitions predict subsequent changes in these outcomes. Further, the two-week ITP can be considered noninferior to the three-week ITP in both clinical outcomes and overall satisfaction., Conclusions: In the context of intensive PTSD treatment, the content of the ITP appears to matter more than its overall length. Shorter programs have the potential to increase access and treatment capacity. Our findings demonstrate the importance of continuous and rigorous program evaluation. Limitations as well as future directions for research, such as identifying the most effective treatment components, are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Intensive treatment programs (ITPs) are successful at reducing posttraumatic stress disorder (PTSD) and depression symptoms in veterans. However, the role of the working alliance in the context of ITPs is largely unexplored. The purpose of this study was to examine veteran-rated working alliance with their individual cognitive processing therapy (CPT) provider as a predictor of changes in PTSD and depression symptoms as well as negative posttrauma cognitions in two unique ITP formats. Data were collected from 128 veterans who completed a 2-week ITP, involving 2 × individual CPT/day, as well as 73 veterans who completed a 3-week ITP, involving 1 × group CPT/day and 1 × individual CPT/day. Both ITPs included adjunctive wellness, skills, and psychoeducation services in addition to CPT. Linear mixed-effects models were used to determine whether changes in working alliance predicted changes in PTSD and depression symptoms. Stronger veteran-reported working alliance with their individual CPT therapist, most notably agreement on tasks, predicted significant reductions in both the 2-week and 3-week programs in PTSD ( p s = .012 and .002, respectively) and depression symptoms ( p s = .009 and .007, respectively) and negative posttrauma cognitions ( p s = .009 and .016, respectively). These results highlight the importance of veterans' perceived working alliance with their individual treatment therapists in ITPs. Results suggest that a strong working alliance that is meaningful for treatment outcomes can be developed quickly despite the brevity of this intensive treatment format. Future research should examine ways to facilitate the development of a strong working alliance prior to or as early as possible in ITPs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective: Evidence-based treatments for posttraumatic stress disorder (PTSD) can be effectively delivered over telehealth. There are, however, no studies that examine the effectiveness of delivering evidence-based treatments for PTSD in an intensive format via telehealth. Telehealth may be well-suited as a delivery modality because it may address barriers specific to intensive treatments., Method: To address this gap, we report on a case series of ten consecutively enrolled veterans (60% male; mean age 42.3, SD = 6.3) who participated in a virtual 2-week, cognitive processing therapy (CPT)-based intensive program., Results: All (100%) participants completed treatment and reported large reductions in PTSD and depression symptoms pre- to posttreatment (Hedge's g ws = 2.83 and g ws = 1.97, respectively), pre- to 3-month follow-up (Hedge's gws = .99 and g ws = 1.24, respectively), as well as very high satisfaction., Conclusions: Results of this case series suggest that evidence-based treatments for PTSD can be effectively delivered in intensive formats over telehealth and lay the foundation for more rigorously designed and larger scale research comparing virtual to in-person delivered intensive PTSD treatments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Objective: The purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD)., Method: The present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment., Results: On average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program., Conclusions: The present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Objective: Moral injury is a nascent construct intended to capture reactions to events that violate deeply held beliefs and moral values. Although a model of moral injury has been proposed, many of the theoretical propositions of this model have yet to be systematically studied., Method: We conducted semistructured interviews with eight veterans who reported experiencing morally injurious events during war zone deployments., Results: Using narrative thematic analysis, five main themes and associated subthemes emerged from the data. The main themes capture the timing of the event, contextual factors that affected the decision-making process during the morally injurious event, reactions to the moral injurious event, search for purpose and meaning, and opening up., Conclusion: The findings from the present study supported an existing model of moral injury, while extending it in several important ways. Preliminary clinical recommendations and directions for future research are discussed based on the study findings. These include directly exploring the context surrounding the morally injurious event, examining the veterans' moral appraisals, and helping them assume appropriate responsibility for their actions to reduce excessive self-blame. (PsycINFO Database Record (c) 2019 APA, all rights reserved).