you will use the five (5) sources below to address the chosen topic.  you are, in essence, building your literature review (introduction section) for your final paper. A literature review is both a summary as well as an explanation of knowledge. 

 Next, based on your understanding of each article, answer the following questions that pertain to essential literature review elements:  

 

1. Summarize the claims made by the authors of the existing research in the field regarding the topic you have chosen. (Make sure you explain the claims the authors made about their researched topic as well as the conclusions they reached).
2. Describe the specific research designs used in the presented research and explain how these designs were used to address the research topic. For example, what were the specific methods used to address their research questions? What types of research design(s) were used (be specific)? (make sure you briefly include the number of participants, their demographics (gender, age, and so forth if the article provides them), and briefly explain where and how the research was conducted (the procedure).
3. How did the research designs used by researchers help in conducting their research?
4. Do you think the research in each of the articles was conducted in an ethical manner? Why or why not?
5. What overall conclusions can be reached by you, based on your own review and presentation of these studies and references?

 Two samples of how you should structure the information in your literature review are attached along with the rubric. Although the samples do not contain all of the information required for this milestone, it should give you an idea. Please follow the examples I have provided. 

 

Your submission for this milestone must follow the  APA paper guidelines. Your submission should not exceed 5-6 pages (excluding the cover and reference pages). It should include a cover page and reference page, be written with 12-point Times New Roman font and double spacing, and you will follow proper APA citation and reference format.

Any thoughts that are not your own MUST be cited in proper APA format. Direct quotes (short and long) MUST be cited and formatted following APA guidelines. Even if you paraphrase information, it MUST be cited.

Attached is all the supporting details 

articles in pdf file – also my question and the articles is full citation 

examples on how it’s written 

My research proposal is PTSD in Veterans and suicide

1) My question is what are the causes of PTSD in veterans and how successful is the current treaments and support systems in place to help them.

2) These are my articles

· Alyson K. Zalta, Philip Held, Dale L. Smith, Brian J. Klassen, Ashton M. Lofgreen, Patricia S. Normand, … Niranjan S. Karnik. (2018). Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD. BMC Psychiatry, (1), 1.

https://doi-org.ucamia.cobimet4.org/10.1186/s12888-018-1816-6

i) This article is about the intense study of evident based study on the treatment and success of a three-week outpatient program. It shows the statistics on the success rate of the program and how it can be implemented and modified to get the most optimal success rates.

· Ashley N. Clausen, Joan Thelen, Alex J. Francisco, Jared Bruce, Laura Martin, Joan McDowd, & Robin L. Aupperle. (2019). Computer-Based Executive Function Training for Combat Veterans With PTSD: A Pilot Clinical Trial Assessing Feasibility and Predictors of Dropout. Frontiers in Psychiatry.

https://doi-org.ucamia.cobimet4.org/10.3389/fpsyt.2019.00062

i) This article is about a new treatment to explore the feasibility of placebo-controlled, computerized, home-based executive function training (EFT) on psychological and neuropsychological function and brain activation in combat veterans with PTSD

· Dorthe Varning Poulsen. (2017). Nature-based therapy as a treatment for veterans with PTSD: what do we know? Journal of Public Mental Health, 16(1), 15–20.

https://doi-org.ucamia.cobimet4.org/10.1108/JPMH-08-2016-0039

i) This paper is about an alternative method of treating PSTD and it has to do with a more holistic approach and a more natural treatment method instead of strong medications.

· Harold G. Koenig, Donna Ames, & Arndt Büssing. (2019). Editorial: Screening for and Treatment of Moral Injury in Veterans/Active Duty Military With PTSD. Frontiers in Psychiatry.

https://doi-org.ucamia.cobimet4.org/10.3389/fpsyt.2019.00596

i) this article is about a new form of PTSD called MI or moral injury. MI defined as the emotional, spiritual, and moral consequences of committing and/or observing others commit transgressions and how it affects them.

· Katherine D. Hoerster, Sarah Campbell, Marketa Dolan, Cynthia A. Stappenbeck, Samantha Yard, Tracy Simpson, & Karin M. Nelson. (2019). PTSD is associated with poor health behavior and greater Body Mass Index through depression, increasing cardiovascular disease and diabetes risk among U.S. veterans. Preventive Medicine Reports.

https://doi-org.ucamia.cobimet4.org/10.1016/j.pmedr.2019.100930

i) This article talks about how PTSD is associated and is clinically proven to worsen and lead to poor health behaviors, depression which leads to CVD and diabetes.

1

CREDIBLE EVIDENCE EVALUATION 2

CREDIBLE EVIDENCE EVALUATION 2

Running head:

Title

Name

The source, “Parents’ Assessment of Parent-Child Interaction Interventions,” hopes to address parent-child intervention pertaining to children with aggressive behavior. The purpose of this study was “to examine long term and short term changes regarding the parents’ experience of parental stress, parental attachment patterns, the parents’ mental health and life satisfaction, the parents’ social support and the children’s problems” (Neander & Engström, 2009). The participants consisted of 101 families with a total of 118 children being assessed (Neander & Engström, 2009). The study showed that after six months the parents did show clear signs of improvement and it was later confirmed when revisited a year later (Neander & Engström, 2009). We also see how attachment theory was the central theory applied to this research (Neander & Engström, 2009). The method is able to provide insight into how a child develops and the link to the relationship it has with its parents. Attachment theory was used in the article to emphasize on the importance of early relationships (Neander & Engström, 2009).

The source “Parents’ Assessment of Parent-Child Interaction Interventions,” conforms to the ethical guidelines because they never reveal any of the participants names or private information. They also state that they were approved by the Research Ethics Committee of

Orebro. Under the Ethical Approval heading it reads “This study has been approved by the Research Ethics Committee of Orebro # 319/02.” (Neander & Engström, 2009). Other then that, the authors didn’t elaborate more on what other ethically measurements they took when conducting the research and the writing of this article.

The source, “Prevention and Intervention for the Challenging Behaviors of Toddlers and

Preschoolers,” hopes to address the problem of challenging behaviors in young children. The purpose of for this research was to show that early identification and prevention would later on have a positive impact on the child’s life. The goal of the research was to be able to establish a system between intervention techniques for normal toddlers, children at-risk, and children with delays and/or persistent challenges (Powell, Dunlap, & Fox, 2006, p. 27). The results provided different levels of prevention and intervention all depending on the needs of the child. The researchers suggest that early intervention and prevention are key when it comes to controlling aggressive and challenging behaviors (Powell, Dunlap, & Fox, 2006). When looking at the support triangle we’re able to see the four levels of prevention and intervention based upon the appropriate needs at each level. The support triangles four levels of prevention and intervention are able to provide, “activities and practices that promote children’s healthy social and emotional development within home and early education and care environments.” (Powell, Dunlap, & Fox, 2006, p. 27). The research focuses on the concept of social competence, suggesting pro-social interactions help improve children’s self-confidence, relationship skills, and self-regulation (Powell, Dunlap, & Fox, 2006) .

The article was a review of literature and did not present an original research study. Since they did not conduct research on people they did not have to obtain consent. As previously stated, since there weren’t any people in the research no consent was needed indicating to the reader their compliance with the ethical guidelines.

References

Neander, K., & Engström, I. (2009). Parents’ assessment of parent-child interaction interventions

– A longitudinal study in 101 families. Child and Adolescent Psychiatry and Mental

Health, 3(8). doi:10.1186/1753-2000-3-8

Powell, D., Dunlap, G., & Fox, L. (2006). Prevention and intervention for the challenging behaviors of toddlers and preschoolers. Infants & Young Children, 19(1), 25–35.

Retrieved from https://depts.washington.edu/isei/iyc/powell_19.1_05

Milestone2: Literature Review/Introduction Grading Rubric

Critical Elements

Proficient (100%)

Needs Improvement (70%)

Not Evident (0%)

Value

Literature Summary & Claims

Summarizes the claims and conclusions presented in the selected articles using
rich detail

Summarizes the claims and conclusions presented in the selected articles, but
summary is cursory and/or contains
inaccuracies

Does not summarize the claims and conclusions presented in the selected
articles

15points

Research Design description

Describes the specific research design(s) used in the selected articles AND explains how they were utilized in rich
detail

Describes the specific research design(s) used in the selected articles AND explains how
they were used, but description is cursory
and/or contains inaccuracies

Does not describe the specific research design(s) used in the selected articles nor explains how they were used

15points

Research design help

Describes how the research designs used in the presented articles assisted in conducting the research

Describes how the research designs used in the presented articles assisted in conducting the research but description is cursory and/or
contains inaccuracies

Does not describe how the research designs used in the presented articles assisted in conducting the research

10points

Ethics

Explains whether or not the presented research was conducted in an ethical manner and uses specific examples from the articles to demonstrate this

Explains whether or not the presented research was conducted in an ethical manner but description is cursory, contains inaccuracies, and/or lacks examples from the
articles

Does not explain whether or not the presented research was conducted in
an ethical manner

10points

Overall conclusions

Explains the overall conclusions that can be reached based on analysis of the
selected articles

Explains the overall conclusions that can be reached based on analysis of the selected
research but description is cursory and/or
contains inaccuracies

Does not explain overall conclusions based on the analysis of the selected
articles

5points

Writing Mechanics

Writing is in APA format, easily understood, clear, and concise using proper citation methods where
applicable with no errors in citations,
references & grammar

Writing is understandable using proper citation methods where applicable with a
number of errors in APA format, citations,
references, & grammar

Writing is very difficult to understand, does not use proper citation methods where applicable and has significant
errors in APA format, references, &
grammar

5points

Total

100% (60points)

1

CREDIBLE EVIDENCE EVALUATION 2

CREDIBLE EVIDENCE EVALUATION 2

Running head:

Title

Name

The first source, “Mental Health Beliefs and Their Relationship With Treatment Seeking Among U.S. OEF/OIF Veterans,” describes through the data collected, the multitude of barriers to care many veterans may face in their lifetimes. This study’s data was collected and analyzed through the use of surveys that asked questions pertaining to the concerns around stigma that veterans believe exist in the workplace and among their loved ones, along with their negative beliefs surrounding mental illnesses, treatment seeking and the treatment itself. The study included 640 participants with the weight of male and female genders having been over-sampled to allow for a gender-stratified analysis. The goals of this study were broken down into three “aims” provided by the researchers and was to obtain a better understanding as to why veterans who suffer from PTSD, depression, or substance abuse do not seek counsel for their trauma due to the stigmas surrounding it and the personal beliefs of the sampled veterans. The study’s primary aim was to collect data from said veterans to identify the concerns around stigma in the workplace and from loved ones versus the actual beliefs of the veterans that surround mental health illness and treatment. A secondary aim was to compare the beliefs of veterans diagnosed with some form of a mental health problem alongside those with a sane mind. The final aim of the study was to provide a correlation between the beliefs around mental health along with its treatments and the actual follow through and use of the care (Vogt, Fox, & Di Leone, 2014). Vogt, Fox, & Di Leone (2014) met an important goal being that of understanding that the belief of an individual veteran and the stigma they hold within themselves is a far more important barrier to overcome than that of military culture, society, or loved ones. According to the researchers this study will need to be conducted with a more longitudinal time-frame along with more participants. The use of “neutral” or unsure responses was simply too great and not enough data could collected to certify their hypotheses (p. 312-313). The authors mention two psychological concepts within the source’s study which include “barriers to care” and

“incorporated negative beliefs” among veterans, their workplace, and loved ones directed toward mental health problems, treatments, and the stigmas surrounding the whole. These concepts were used by the authors as a foundation for the study allowing them to direct and control their efforts to obtain objective data solely pertaining to their hypotheses (Vogt, Fox, & Di Leone, 2014).

This study conforms to APA Ethics Code 8.02 “Informed Consent to Research” because of its process of obtaining information through a survey system. The importance of ensuring the participants had enough information in order to give consent remained at the forefront for the researchers and was demonstrated through the consistent sending of the assessment packages along with reminders in the mail over an 11 week span in efforts to gain credibility and receive maximum participation (Vogt, Fox, & Di Leone, 2014, p. 308). This study does contain what may be assumed as an offering of inducement which is the $20 gift card, however that is disregarded due to the gift card being rewarded regardless of participation. The source also does not contain any information regarding the participants which is implied to be in compliance of the ethical guideline pertaining to confidentiality and privacy.

The second source, “Help-Seeking Stigma and Mental Health Treatment Seeking Among Young Adult Veterans,” is the first study of its kind which includes literature that assesses the relationship between the public and perceived public stigmas. This study primarily focuses on the study of 812 young adult veterans between ages 18-35 and also varied with demographic factors to include ethnicity, gender, and symptom severity. The goal of the researchers within this study was to open a door in which has not yet been opened to better understand and comprehend the stigmas that surround mental health and the variety of ways to seek help. The purpose of this study is to correct the misperceptions many persons hold today surrounding these stigmas and to develop solutions so that the veterans that so desperately need help yet are afraid of the judgement will be able to happily, humbly, and safely obtain the assistance they so desire (Kulesza, Pedersen, Corrigan, & Marshall, 2015). The study was conducted using a large online cross-sectional survey brought about information untouched in the field as of yet. In the research of Kulesza, Pedersen, Corrigan, & Marshall (2015) they were able to understand that it is the veterans themselves which alter and halt the use of mental health services as it is noted that 88% of veterans admit they would not look down upon a fellow veteran seeking assistance. Despite the great efforts by the individuals of this study it still remains difficult to obtain absolute certainty using these surveys due to certain shortcomings which include misrepresentation along with concerns about safety and confidentiality. Nonetheless the confident findings will lead to solutions to correcting misperceptions such as targeting individual veterans who unbiased and using interventions to assist in deletion of the surrounding stigmas. This source identifies two theories or frameworks which include the “Attribution Theory (AT)” and the “Modified labeling theory (MLT)”. AT is consisted of the population of people who discriminate against veterans with mental health problems saying they are dangerous and to blame for their mental state – this is also referenced as the public stigma. MLT accounts for those that aware of such judgement and discrimination that in turn decide to avoid to the situation in its entirety – this is also referenced as the perceived public stigma (Kulesza, Pedersen, Corrigan, & Marshall, 2015).

This study conforms to APA Ethics Code 8.02 “Informed Consent to Research” because of its process of utilizing Facebook to gain consent for the participants of the survey. This study also conforms to APA ethics code 8.06 “Offering Inducements for Research Participation” because of its rewarding of a $20 gift cards to all who make the decision of moving forward with the process. To enter the process of consent and so forth one looks upon the advertisement or “offering of inducement” of a $20 gift card upon given consent of confirmation of participation. The researchers gained initial consent from the participant using Facebook, however the study does not reveal any participants personal information (Kulesza, Pedersen, Corrigan, & Marshall, 2015). The offering of the $20 gift card to each participant is implied to be within Standard 8.06 although some may argue the offering seeks more participation, the amount is not excessive in nature and does not offset the yield.

References

Kulesza, M., Pedersen, E. R., Corrigan, P. W., & Marshall, G. N. (2015). Help-seeking stigma and mental health treatment seeking among young adult veterans. Military Behavioral

Health, 3(4), 230–239. doi:10.1080/21635781.2015.1055866

Vogt, D., Fox, A. B., & Di Leone, B. A. L. (2014). Mental health beliefs and their relationship with treatment seeking among U.S. OEF/OIF veterans. Journal of Traumatic Stress, 27,

307–313. doi: 10.1002/jts.21919

1 August 2019 | Volume 10 | Article 596

EDITORIAL

doi: 10.3389/fpsyt.2019.00596

published: 21 August 2019

Frontiers in Psychiatry | www.frontiersin.org

Edited and reviewed by:
Paul Stokes,

King’s College London,
United Kingdom

*Correspondence:
Harold G. Koenig

Harold.Koenig@duke.edu

Specialty section:
This article was submitted to
Mood and Anxiety Disorders,

a section of the journal
Frontiers in Psychiatry

Received: 05 July 2019
Accepted: 29 July 2019

Published: 21 August 2019

Citation:
Koenig HG, Ames D and Büssing A

(2019) Editorial: Screening for and
Treatment of Moral Injury in Veterans/

Active Duty Military With PTSD.
Front. Psychiatry 10:596.

doi: 10.3389/fpsyt.2019.00596

Editorial: Screening for and Treatment
of Moral Injury in Veterans/Active Duty
Military With PTSD
Harold G. Koenig 1,2,3*, Donna Ames 4,5 and Arndt Büssing 6,7

1 Department of Psychiatry and Behavioral Sciences and Department of Medicine, Duke University Medical Center, Durham,
NC, United States, 2 Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, 3 School of Public Health,
Ningxia Medical University, Yinchuan, China, 4 Department of Psychiatry, VA Greater Los Angeles Healthcare System, Los
Angeles, CA, United States, 5 Department of Psychiatry, David Geffen School of Medicine at UCLA, Los Angeles, CA, United
States, 6 Quality of Life, Spirituality and Coping, Faculty of Health, Witten/Herdecke University, Witten, Germany,
7 IUNCTUS—Competence Center for Christian Spirituality, Philosophical-Theological Academy, Münster, Germany

Keywords: moral injury, PTSD, definition, screening, veterans

Editorial on the Research Topic

Screening for and Treatment of Moral Injury in Veterans/Active Duty Military with PTSD

Moral injury (MI) is a relatively new syndrome, yet one that has been around for a long time. MI often
accompanies posttraumatic stress disorder (PTSD) and is especially common in active duty military
(ADM) and veterans as a result of combat experiences and other military-related traumas. MI may
also be common in noncombat veterans, health professionals, and even civilian populations. The
purpose of this Research Topic is to define and describe MI in veterans and ADM, examine how it is
assessed and differentiated from PTSD, and begin to explore ways that psychiatrists and other health
professionals can identify and address it. In this issue, we present perspectives and new research on
MI from around the world, including the USA and Canada, Australia, France, and Germany.

When it occurs in the military, MI has been defined as the emotional, spiritual, and moral
consequences of committing and/or observing others commit transgressions of deeply held moral values
during combat or combat-related circumstances (1). Another common definition describes MI as “a
betrayal of what’s right, by someone who holds legitimate authority, in a high-stakes situation” (2), in
other words, betrayal by commanders who may have placed service members in a position that forced
them to transgress moral boundaries. Brief measures now exist that have been psychometrically validated
to identify symptoms of MI among veterans and those currently in the military (3). Research has shown
that >50% of ADM with PTSD symptoms have four or more symptoms of MI in the severe range (9 or 10
on a 1–10 scale) (4), and nearly 60% of veterans with PTSD have five or more such symptoms (5).

In the past decade, we have learned that moral injuries of this type can have devastating consequences
on mental health, causing severe anxiety, depression, hopelessness, and suicide among ADM and veterans
(6). Given the many challenges involved in successfully treating military-related PTSD, clinicians are often
so focused on PTSD symptoms and comorbid disorders (mood disorders, substance abuse, risk of suicide,
etc.) that they fail to recognize underlying moral injuries that may be driving these disorders (1). Growing
research suggests that PTSD and MI are distinct but overlapping conditions (7). Failure to recognize and
address MI may impair successful treatment of PTSD, at least partly explaining why PTSD outcomes
are so poor despite the best pharmacological and psychotherapeutic treatments now available (8).

While especially common in military settings, MI is also experienced by those outside the military.
Much recent attention has been paid to rising suicide rates and burnout among physicians and nurses,
which may be linked to moral injuries that occur in high stakes situations involving life and death
decisions that these health professionals make (9). Likewise, victims of sexual and racial abuse may

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Editorial: Moral Injury in the MIlitaryKoenig et al.

2 August 2019 | Volume 10 | Article 596Frontiers in Psychiatry | www.frontiersin.org

experience shame, guilt, anger, and undergo spiritual struggles.
Although we focus here on MI acquired in military settings, future
research should seek to identify and treat noncombat veterans,
civilians in high-risk professions (physicians, nurses, police,
firemen, other first responders), and those with a history of trauma
(abuse, rape) who may experience similar symptoms.

New approaches to the treatment of MI in the setting of PTSD
are now being developed and tested in randomized controlled
trials (10, 11, 12). These treatments provide hope and the promise
of relief to millions of ADM and veterans who currently suffer
from PTSD and related disorders. Before psychiatrists and mental
health professionals can take advantage of these new treatments,
however, they need to know how to identify MI, who to refer
to, and what kinds of treatments are available to help those with
a condition that may afflict more than half of current military
personnel and veterans with PTSD symptoms. This Research
Topic is designed to assist and inform in this regard.

In the first article, Koenig et al. review and discuss the definition
of MI and the way that it has been conceptualized and measured
among veterans and ADM, making recommendations for both
investigators who conduct research in this area and clinicians who
must screen for this syndrome in clinical practice. In the second
article, Brémault-Phillips et al. briefly review past research on MI
and mental health outcomes in the setting of PTSD among current
and former military personnel. Next, Kopacz et al. illustrate this
by exploring the association between loss of trust (a key symptom
of MI) and mental health among 427 veterans and ADM with
combat-related PTSD symptoms. Frankfurt et al. then delve into
the mechanisms (direct and indirect pathways) by which MI occurs
as a result of two specific types of military-related trauma in US
Veterans, sexual trauma and combat exposure.

The next five articles focus on treatment. Belrose et al. present a
new approach to the challenge of reintegrating soldiers with chronic
PTSD back into civilian life in France. Carey and Hodgson follow

with an article on how clinicians can identify and treat MI, drawing
on their experience from Australia and illustrating the important
role that military chaplains play in addressing this syndrome. Next,
Büssing et al. draw on data from a large study of German soldiers,
emphasizing the need to talk about experiences during combat, the
need to forgive others, and the need to be forgiven for transgressions,
ultimately leading to healing of moral injuries experienced during
war. Purcell and colleagues then discuss why forgiveness is so
important to US Veterans who feel guilt and shame about their
actions in war, what type of forgiveness is attainable and meaningful,
and what role clinicians can play in facilitating forgiveness. Finally,
Smith-MacDonald et al. examine the spiritual dimensions of MI in
the Canadian armed forces, describing what chaplains in this setting
have to offer military personnel and their families.

This Research Topic promises to update readers on the latest
research and discussions on this common, consequential, and often
neglected syndrome. These articles will provide researchers with the
best available tools to further explore the relationship between MI
and mental health outcomes and to develop effective interventions,
as well as inform and equip clinicians to identify MI in high-risk
ADM and veterans and monitor response to treatment.

AUTHOR CONTRIBUTIONS

Each of the authors (HK, DA, and AB) have contributed
intellectual content and have contributed to the actual writing
of the editorial.

FUNDING

Funding support for this article was provided by the Center
for Aging and Human Development, Duke University Health
Systems, Durham, North Carolina.

REFERENCES

1. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, et al. Moral injury
and moral repair in war veterans: a preliminary model and intervention
strategy. Clin Psychol Rev (2009) 29:695–706. doi: 10.1016/j.cpr.2009.07.003

2. Shay J. Achilles in Vietnam: combat trauma and the undoing of character. New
York, NY: Scribner (1994).

3. Koenig HG, Ames D, Youssef N, Oliver JP, Volk F, Teng EJ, et al. Screening
for moral injury—the moral injury symptom scale-military version short
form. Mil Med (2018) 183(11–12):e659–65. doi: 10.1093/milmed/usy017

4. Volk F, Koenig HG. Moral injury and religiosity in active duty US
Military with PTSD symptoms. Mil Behav Health (2019) 7(1):64–72. doi:
10.1080/21635781.2018.1436102

5. Koenig HG, Youssef NA, Ames D, Oliver JP, Teng EJ, Haynes K, et al. Moral injury
and religiosity in U.S Veterans with posttraumatic stress disorder symptoms.
J Nerv Ment Dis (2018) 206(5):325–31. doi: 10.1097/NMD.0000000000000798

6. Ames D, Erickson Z, Youssef NA, Arnold I, Adamson CS, Sones AC, et al.
Moral injury, religiosity, and suicide risk in U.S veterans and active duty
military with PTSD symptoms. Mil Med (2018) 184(3–4):e271–8. doi:
10.1093/milmed/usy148

7. Koenig HG, Youssef NA, Ames D, Teng EJ, Hill TD. Examining the overlap
between moral injury and PTSD in U.S. Veterans and active duty military.
J Nerv Ment Dis (2019).

8. Koenig HG, Boucher NA, Oliver JP, Youssef N, Mooney SR, Currier JM,
et al. Rationale for spiritually-oriented cognitive processing therapy for

moral injury in active duty military and veterans with post-traumatic
stress disorder. J Nerv Ment Dis (2017) 205(2):147–53. doi: 10.1097/
NMD.0000000000000554

9. Ford EW. Stress, burnout, and moral injury: the state of the healthcare workforce.
J Healthc Manag (2019) 64(3):125–7. doi: 10.1097/JHM-D-19-00058

10. Harris JI, Erbes CR, Engdahl BE, Thuras P, Murray-Swank N, Grace D, et al. The
effectiveness of a trauma focused spiritually integrated intervention for veterans
exposed to trauma. J Clin Psychol (2011) 67:425–38. doi: 10.1002/jclp.20777

11. Litz BT, Lebowitz L, Gray MJ, Nash WP. Adaptive disclosure: a new treatment
for military trauma, loss, and moral injury. NY, NY: The Guilford Press
(2017).

12. Pearce M, Haynes K, Rivera NR, Koenig HG. Spiritually-integrated cognitive
processing therapy: a new treatment for moral injury in the setting of PTSD.
Glob Adv Health Med (2018) 7:1–7. doi: 10.1177/2164956118759939

Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.

Copyright © 2019 Koenig, Ames and Büssing. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums is permitted, provided the original
author(s) and the copyright owner(s) are credited and that the original publication
in this journal is cited, in accordance with accepted academic practice. No use,
distribution or reproduction is permitted which does not comply with these terms.

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https://doi.org/10.1016/j.cpr.2009.07.003

https://doi.org/10.1093/milmed/usy017

https://doi.org/10.1080/21635781.2018.1436102

https://doi.org/10.1097/NMD.0000000000000798

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https://doi.org/10.1097/NMD.0000000000000554

https://doi.org/10.1097/NMD.0000000000000554

https://doi.org/10.1097/JHM-D-19-00058

https://doi.org/10.1002/jclp.20777

https://doi.org/10.1177/2164956118759939

http://creativecommons.org/licenses/by/4.0/

• Editorial: Screening for and Treatment of Moral Injury in Veterans/Active Duty Military With PTSD

Author Contributions
Funding
References

RESEARCH ARTICLE Open Access

Evaluating patterns and predictors of
symptom change during a three-week
intensive outpatient treatment for veterans
with PTSD
Alyson K. Zalta1,2* , Philip Held1, Dale L. Smith3, Brian J. Klassen1, Ashton M. Lofgreen1, Patricia S. Normand1,
Michael B. Brennan1, Thad S. Rydberg1, Randy A. Boley1, Mark H. Pollack1 and Niranjan S. Karnik1

Abstract

Background

: Intensive 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]).

Method

: One-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.

Results

: Pre-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.

Conclusion: Intensive 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.

Keywords: Veteran, Military, Posttraumatic stress disorder, Combat, Military sexual trauma, Intensive treatment,
Cognitive processing therapy, Mindfulness

* Correspondence: azalta@uci.edu
1Rush University Medical Center, Chicago, IL 60612, USA
2University of California, Irvine, Irvine, CA 92697, USA
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Zalta et al. BMC Psychiatry (2018) 18:242
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Background
According to a recent meta-analysis, approximately 23% of
veterans returning from Operation Enduring Freedom and
Operation Iraqi Freedom develop posttraumatic stress dis-
order (PTSD) [1]. Although evidence-based psychother-
apies for PTSD such as Cognitive Processing Therapy
(CPT) [2, 3] and Prolonged Exposure [4] exist, many vet-
erans do not receive these treatments or fail to receive a
sufficient dose of treatment [5]. Research shows that nearly
40% of veterans terminate evidence-based PTSD treatment
prior to receiving therapeutic benefit [6]. Several barriers
may contribute to low utilization of evidence-based PTSD
treatment among veterans including avoidance [7] and poor
accessibility of treatment [8, 9].
It is clear that there is a need for greater provision of

evidence-based PTSD treatment that is able to address
these barriers to its effective utilization. An increasingly
popular approach is to deliver these therapies intensively
(i.e., daily treatment with patients often living at or near the
treatment site during the treatment period) to reduce the
susceptibility to external distractions and practical barriers
to engaging in treatment, and provide less opportunity for
avoidance. Intensive treatments also allow for the integra-
tion of multiple treatment modalities, including case man-
agement and integrative modalities, which may support
treatment adherence and provide more comprehensive care
as compared to traditional outpatient therapy. For example,
research has shown that the addition of case management
services can reduce dropout from cognitive behavioral ther-
apy in vulnerable populations [10].
Residential treatment programs for PTSD typically offer

daily treatment over the course of 6–12 weeks with evi-
dence-based treatment (e.g., CPT) delivered twice per
week [11–15]. In addition to evidence-based treatment,
these programs offer other therapeutic interventions in-
cluding medication management, psychoeducation, and
wellness interventions. Evidence suggests that the delivery
of CPT in residential treatment is effective in reducing
PTSD and depression symptoms in veterans with different
types of trauma (e.g., combat, MST) and comorbidities
(e.g., traumatic brain injury, substance abuse) [11–15].
However, the length of time required to complete these
programs is often a significant practical barrier for veterans
due to concerns about being away from family and work
for such a significant period of time.
Several recent studies have shown that more intensive

outpatient programs that offer daily evidence-based treat-
ment delivered over the course of 3 weeks are also effective
for active duty service members and veterans with PTSD
[16, 17]. Lande and colleagues [16] evaluated a three-week
intensive outpatient program (IOP) for 39 active duty ser-
vice members with combat-related PTSD that incorporated
daily group and individual cognitive behavioral therapy, cop-
ing skill education, medication management, art therapy,

and biofeedback. Participation in the IOP resulted in
significant reductions in PTSD and depressive symp-
toms with medium effect sizes [16]. Beidel and col-
leagues [17] evaluated a 3-week IOP treatment for
post 9/11 veterans (N = 112) that incorporated daily
individual exposure therapy and daily group therapy
focusing on behavioral activation, social skills, and
anger management. The study revealed large reduc-
tions in PTSD symptoms, depression symptoms, guilt,
and anger from pre- to posttreatment and these gains
were maintained at 6-month follow-up. Moreover, in
this study, treatment dropout was much lower than
what is typically seen in traditional outpatient
treatment.
These findings suggest that IOPs are a promising avenue

for delivering evidence-based treatment to veterans and ser-
vice members with PTSD. However, existing studies have
only evaluated key outcomes before and after treatment
and have not evaluated the patterns of symptom change of
symptom change over the course of treatment. Under-
standing how veterans improve over the course of intensive
treatment is important for establishing the proper dose of
treatment, a key question for balancing the feasibility and
effectiveness of these programs. Specifically, examining
treatment change during the intervention will allow us to
determine whether patients plateau and whether shorter in-
terventions would be worthwhile. Moreover, evaluating pre-
dictors of treatment response to determine who is most
likely to benefit and how they benefit is critical for optimiz-
ing the dissemination of intensive treatments.
With women having an increasingly larger presence in

the military, it is important to evaluate whether intensive
PTSD treatment programs work equally well for men
and women and for different trauma types (i.e., combat
and military sexual trauma [MST]). One large Veteran’s
Administration (VA) study combining data across seven
different PTSD intensive treatment programs showed that
sex and a history of military sexual assault did not predict
treatment outcome [18]. However, this study was lim-
ited by the fact that they combined data across very
different types of treatment programs and overall the
treatment effect sizes were small, suggesting that these
programs were not as effective as the intensive outpatient
programs [16, 17]. Another VA study examining a 7-week
residential PTSD treatment showed that women had a
greater decrease in clinician-rated and self-reported PTSD
symptoms than men over the course of treatment, but
having MST as the index trauma did not predict treatment
response [12]. To our knowledge, no studies to date have
examined sex and MST as a predictor of treatment re-
sponse to more condensed intensive outpatient treatment
programs.
With respect to how individuals benefit from treat-

ment, current evidence suggests that changes in

Zalta et al. BMC Psychiatry (2018) 18:242 Page 2 of 15

posttraumatic cognitions may be an important mechan-
ism of cognitive-behavioral treatments for PTSD [19],
including Cognitive Processing Therapy [20]. Schumm
and colleagues [21] reported that changes in posttraumatic
cognitions preceded changes in PTSD symptoms for vet-
erans receiving CPT in a 7-week residential treatment pro-
gram. However, this study relied on only 3 time points of
measurement (pre, mid, post) and no studies have evalu-
ated whether changes in posttraumatic cognitions predict
treatment response in more intensive treatment models.
The current study sought to address these important

gaps in the literature using effectiveness data from an
all-day three-week, cohort-based IOP for service members
and veterans with PTSD. The IOP included two treatment
tracks (combat-based PTSD and MST-based PTSD), both
of which included co-ed cohorts. The goals of the current
study were to 1) evaluate patterns of PTSD and depression
symptom change over the course of the IOP, 2) examine
sex and cohort type (combat vs. MST) as predictors of
treatment response, 3) examine changes in posttraumatic
cognitions as a predictor of treatment response, and 4)
examine whether the relationship between changes in
posttraumatic cognitions and treatment response differed
by sex or cohort type (combat vs. MST).

Method
Intervention
Service members and veterans in this sample participated
in a three-week, co-ed, cohort-based IOP designed to treat
PTSD secondary to military trauma. The program is
housed within a non-VA, mental health clinic that pro-
vides services to individuals who served in the U.S. mili-
tary and their family members free-of-charge. The
program runs from 8:00 am to 5:00 pm from Monday
through Friday over the course of 3 weeks (15 days of
treatment delivered over 19 days). Following the clinical
intake evaluation, eligible IOP participants were assigned
to one of two IOP tracks (combat or MST) based on their
identified index trauma; the treatment tracks ran non-
concurrently (for a description of patient flow into the
program see Held et al.: Feasibility and acceptability of a
three-week intensive outpatient treatment program for
service members and veterans with PTSD, in submission).
The combat track was designed to meet the needs of
veterans experiencing PTSD secondary to combat or
warzone stressors. The MST track was offered to vet-
erans with PTSD who experienced military sexual trauma
and reported a sexual trauma as their index trauma. Inter-
ventions offered in both tracks were largely the
same, although some minor modifications were made
to address issues specific to each population (e.g.,
topic-specific psychoeducation sessions for MST). Cohort
sizes for both tracks of the program ranged from 5 to 14
participants (M = 10.05, SD = 2.27), and most cohorts were

co-ed. Clinicians were mindful in informing patients about
the co-ed groups prior to treatment initiation and worked
to ensure that at least 2 individuals of the same sex were
in each MST cohort.
The primary IOP intervention components included

daily trauma-focused treatment comprised of individual
and group CPT [2, 3], as well as daily group integrative
health treatment comprised of a mindfulness program
that was based on Mindfulness-Based Stress Reduction
[22] and yoga. Over the course of the 3 weeks, IOP par-
ticipants received 15 sessions of individual CPT, 13 ses-
sions of group CPT, 13 sessions of group mindfulness,
and 12 sessions of yoga. IOP participants were also
assigned daily CPT homework and mindfulness practice.
These interventions were modified slightly depending on
cohort type (combat vs. MST). For example, the MST
track emphasized the esteem and interpersonal difficul-
ties often characteristic of relational trauma.
In addition to these primary intervention components,

several secondary intervention components were offered
during the three-week IOP program. IOP participants
attended experiential and didactic sessions on healthy
living that focused on nutrition and physical activity.
They also participated in art therapy and groups with a
chaplain that focused on making meaning from military
service. Psychoeducation sessions focused on common
challenges in service members with PTSD such as sleep,
pain, relationships, and cognitive health. IOP partici-
pants had the option to do up to 6 sessions of acupunc-
ture, meet with a psychiatrist or nurse practitioner for
medication management, and meet with a VA Liaison
for case management services to assist with continuity
of care upon discharge. They were also offered referrals
for neuropsychological assessment in cases of suspected
traumatic brain injury. Case management services were
provided to address legal, financial, or other psychosocial
needs. IOP participants attended planned weekend social
outings in the city both for enjoyment and as opportun-
ities to practice newly acquired skills (e.g., sports events,
city tours). Psychoeducation sessions were offered to
family members during the third week of the program
in-person or via telehealth. Finally, outreach coordina-
tors worked with participants routinely to ensure that
veterans were connected to appropriate aftercare re-
sources (e.g., psychotherapy, pharmacotherapy, voca-
tional services, meditation groups, yoga classes).

Cognitive processing therapy
Cognitive Processing Therapy (CPT) is an evidence-
based, cognitive-behavioral treatment for PTSD second-
ary to a range of traumatic experiences, including military
trauma and sexual assault [23–25]. The group and individ-
ual CPT protocols were structured to accommodate the
3-week format of the IOP (see Appendix A). The content

Zalta et al. BMC Psychiatry (2018) 18:242 Page 3 of 15

of the individual CPT aligned closely with the CPT proto-
col [2, 3]. CPT groups were used mainly to practice CPT
skills, such as stuck point identification and cognitive re-
structuring using Socratic dialogue. The initial Impact
Statement assignment was modified to facilitate the early
identification of assimilated “stuck points.” All participants
were encouraged to share their Impact Statement in the
groups and group-based Socratic dialogue often led to
uncovering specific details about the various index trau-
mas, which appeared to foster group cohesion. Individual
and group CPT sessions were conducted by licensed psy-
chologists, psychology postdoctoral fellows, licensed clin-
ical social workers, and licensed professional counselors.
All clinicians were trained in CPT by a national subject
matter expert. Clinicians were required to participate in of-
ficial CPT consultation calls following the training and were
either rostered on the CPTforPTSD.com website when see-
ing patients as part of the IOP or working toward becoming
rostered. In addition, all clinicians who saw patients as part
of the IOP received weekly on-site CPT-consultation from
a licensed psychologist with extensive CPT training and ex-
perience. Communication between individual and group
providers was facilitated through weekly CPT consultation
in which the veterans’ stuck points were identified and pri-
oritized for treatment, as well as twice-weekly conference
calls among all the IOP providers.

Mindfulness based resiliency training
Our intervention, Mindfulness Based Resiliency Training
(MBRT) was based on Mindfulness-Based Stress Reduc-
tion (MBSR) [22]. Mindfulness, non-judgmental attention
on present moment experience, was taught as a way to
help participants learn cognitive objectivity, decrease re-
activity, and increase affect tolerance. Sessions were deliv-
ered by trained MBSR teachers. Content of the MBSR
curriculum was maintained but the program was adapted
to accommodate the 3-week format of the IOP. Specific-
ally, the 13 sessions were delivered in 75–90 min and one
of the sessions in week 2 was a mini retreat of practice
without didactics. The yoga (mindful movement) content
of MBSR was taught as a separate hour to have sufficient
time for the MBRT curriculum and to allow family mem-
bers who accompanied participants in the last week to
participate. The order of the MBSR curriculum content
was modified to better align with the CPT curriculum and
two sessions of mindful self-compassion [26] were added
as a way of helping participants who had experienced
moral injury. One session also included an introduction to
the mindfulness smartphone apps, Mindfulness Coach
[27] and Headspace [28]. The daily home practice ses-
sions, consisting of approximately 15 min of formal and
informal mindfulness meditations, were shorter than the
standard MBSR home practice.

Participants
Local and non-local service members and veterans were re-
ferred to the program through a variety of sources, includ-
ing mental health providers/programs, program outreach
coordinators, non-profit veteran and social service organi-
zations, other veterans, as well as self-referral. Potential par-
ticipants completed a comprehensive psychosocial and
diagnostic assessment and a series of online screening mea-
sures. To be eligible for the IOP, veterans had to report a
history of military trauma (e.g., combat or exposure to war-
zone, military sexual trauma) and to have met the diagnos-
tic criteria for PTSD, which was verified by the Clinician
Administered PTSD Scale for DSM-5 – past month version
(CAPS-5) [29]. Service members and veterans were ineli-
gible for the program and referred for a higher of level of
care if they were experiencing clinical issues that would
interfere with their ability to engage in the IOP. Exclusion
criteria included active suicidality or homicidality, current
engagement in non-suicidal self-harm, active mania or
psychosis, active eating disorders, and/or active substance
use that would interfere with ability to participate or pose
risk of physiological withdrawal. Individuals were also ex-
cluded if current medical, legal, or other psychosocial issues
would interfere with their ability to fully engage in treat-
ment (for rates and reasons for exclusion see Held et
al.: Feasibility and acceptability of a three-week intensive
outpatient treatment program for service members and vet-
erans with PTSD, in submission).
The sample for the present study consisted of 191 vet-

erans and service members (94% discharged/retired; 6% on
active duty, reserves, or National Guard; henceforth collect-
ively referred to as “veterans”) who completed a 3-week
IOP between April 2016 and December 2017. This sample
represents 19 cohorts including 12 cohorts of the combat
track (n = 122; 88.5% male) and 7 cohorts of the MST track
(n = 69; 18.8% male). On average, veterans were 41.4 years
old (SD = 9.4, range = 25–69). The majority served in the
military after the September 11th terrorist attacks (89.0%),
had been deployed (81.5%), and were not local (i.e., greater
than 60-mile line-of-sight distance from the mental health
clinic; n = 170, 89.0%). Other demographic and military
characteristics are reported in Table 1.

Assessment procedures
As part of the IOP, veterans completed baseline, post-
treatment, and daily assessments. Prior to enrolling
into the IOP, veterans participated in two 60–90 min
clinical intake evaluations with a licensed psychologist,
psychology postdoctoral fellow, social worker, or licensed
professional counselor. During the intake evaluations, vet-
erans completed a semi-structured psychosocial interview,
were assessed for PTSD using the CAPS-5, and were
asked to complete a battery of self-report assessments. On
average, intake self-report questionnaires were completed

Zalta et al. BMC Psychiatry (2018) 18:242 Page 4 of 15

Welcome

8.25 days (SD = 5.15) before they started the IOP program.
Veterans were asked to complete additional self-report as-
sessments during the IOP and upon completion of the
IOP. All self-report assessments were conducted via Qual-
trics [30], a secure online survey tool. This study was ap-
proved by the Institutional Review Board at Rush University
Medical Center. A waiver of consent was obtained because
all assessments were collected as part of routine care
procedures.

Measures
Demographics
At intake, veterans provided demographic information,
such as age, sex, ethnicity, and education level, as well as
military characteristics, such as service branch, last or

current military pay grade, service era, and discharge
status.

Posttraumatic stress disorder
The primary outcome measure for the study was the
PTSD Checklist for DSM-5 (PCL-5) [31], a 20-item
self-report measure of the DSM-5 symptoms of PTSD.
When completing the measure, veterans were directed
to rate symptoms in relation to their index trauma. As
part of their intake and post-treatment assessments, vet-
erans were asked to rate their PTSD symptoms experi-
enced during the past month. On 9 days during the IOP
(every other day with additional assessments to capture
the beginning and end of treatment), veterans were
asked to report PTSD symptoms experienced during the

Table 1 Demographic and Military Characteristics

Variable n (%)

Male 121 (63.4)

Ethnicity

Not Hispanic or Latino 154 (80.6)

Hispanic or Latino 36 (18.9)

Refused 1 (0.5)

Race

White or Caucasian 130 (68.1)

Black or African American 34 (17.8)

Asian 1 (0.5)

American Indian or Alaskan Native 5 (2.6)

Native Hawaiian or Pacific Islander 3 (1.6)

Other 18 (9.4)

Marital Status

Single 38 (19.9)

Married/domestic partner 90 (47.1)

Divorced/separated 60 (31.4)

Widowed 3 (1.6)

Last or Current Military Pay Grade

E1-E3 23 (12.0)

E4-E9 156 (81.7)

Officer/Warrant Officer 12 (6.3)

Branch

Army/Army Reserve/Army National Guard 124 (64.9)

Air Force/Air Force Reserve/Air National Guard 18 (9.4)

Marine 26 (13.6)

Navy 21 (11.0)

Coast Guard 2 (1.1)

Military Service Status

Discharged / Retired / Medically Retired 180 (94.2)

Active Duty / Reserves / Inactive Ready Reserve / National Guard 11 (5.8)

Note. N = 191

Zalta et al. BMC Psychiatry (2018) 18:242 Page 5 of 15

past week. The past week version of the PCL-5 was used
for the daily measures and endpoint scores because it was
hypothesized to be more sensitive to any changes that
would occur during treatment given that the treatment was
shorter than a one-month period. The PCL-5 has been vali-
dated and shown to have good internal consistency in sam-
ples of veterans and treatment-seeking service members
[31–33]. Internal reliability for the past month PCL-5 at in-
take was .88. Internal reliability of the past week PCL-5 on
day 2 of the program was .88.

Depression
Depression symptoms were assessed as a secondary out-
come measure using the Patient Health Questionnaire – 9
(PHQ-9) [34]. The PHQ-9 is a 9-item self-report measure
of DSM-IV criteria for a Major Depressive Episode. The
measure asks patients to report on symptoms occurring in
the past 2 weeks. The PHQ-9 was assessed during at in-
take, post-treatment, and on 7 days during the IOP. The
measure has been validated and shown to be a have good
reliability and internal consistency with a variety of sam-
ples, including veterans [35, 36]. Internal reliability for the
PHQ-9 at intake was .80.

Posttraumatic cognitions
Posttraumatic cognitions were assessed with the Posttrau-
matic Cognitions Inventory (PTCI) [37]. The PTCI is a
33-item self-report scale that measures trauma-related
thoughts and beliefs including negative cognitions about
the self, self-blame, and negative cognitions about others
and the world. Items are scored from 1 (totally disagree)
to 7 (totally agree). A total score was calculated as the
sum of all items with higher scores indicating stronger en-
dorsement of posttraumatic cognitions. The PTCI has
demonstrated strong reliability and validity [37] including
in military populations with PTSD [38]. Internal reliability
for the PTCI at intake was .95.

Analytic approach for trajectory analysis
Mixed-effects regression models were conducted to exam-
ine the trajectory of treatment response over the course of
the IOP program due to their less restrictive assumptions
regarding the variance-covariance structure, their utility in
accommodating some missing measurements across time-
points, and their ability to model individual change over
time [39]. Likelihood ratio tests were used for significance
testing in mixed effects model comparisons. Some spor-
adic missing data existed for responses across time points
used in longitudinal analyses during the program, though
87.31% of participants utilized in this analysis completed
measurements for PTSD symptoms, and 91.04% partici-
pants completed depression assessments measurements,
during the final two program measurements. Additionally,

missingness was not associated with outcome measures at
any timepoint or any measured variable. All analyses were
conducted in Stata 14 (Statacorp) [40] and Supermix 1.1
(Scientific Software International) [41]. Figures were cre-
ated in Sigmaplot 13 (Systat Software) [42].
Initial examinations of the correlation structure of PTSD

symptom severity (PCL-5) and depression (PHQ-9) scores
over time suggested that measurements closer in time were
indeed more highly correlated, and that correlations within
the same time lags were moderately consistent. This sug-
gested that first-order autoregressive or unstructured co-
variance pattern models were likely appropriate for errors,
which were used for PTSD symptoms and depression
scores, respectively, based on Akiake Information Criterion
(AIC) analysis. Likelihood ratio tests and AIC values indi-
cated that random intercepts models were a significantly
better fit than linear models for both PTSD symptoms and
depression (ps < .001), and random intercepts and trends models were a significantly better fit compared to random intercepts-alone models (ps < .001). A random quadratic trend component also significantly improved fit for PTSD symptom score (p < .001) and thus was retained for all mixed effects regression models predicting PCL-5 score that did not include time-varying covariates.1 To test the hypothesized prognostic factors (sex and cohort type), we examined the main effects of these variables in the model as well as their interactions with time to determine whether treatment response differed over time based on these variables.2

We further examined PTCI scores across the treat-
ment program as a lagged time-varying covariate to
assess the relationships between changes in cognitions
over the course of the program and PTSD and depression
symptoms. PTCI measurements taken on days 2, 4, 9, 11,
and 16 served as predictors of both PCL-5 and PHQ-9 out-
comes on days 3, 5, 10, 12, and 17 while including time,
sex, and cohort type in the models. This also included
examining the interaction of the PTCI with time, decom-
posing within-subject and between-subjects PTCI effects,
as well as adjusting for autocorrelation by including the
most recent PTSD or depression prior outcome measure-
ments as predictors. Of note, intra-class correlations
(ICCs) were greater than .60 for both outcomes, suggest-
ing that a high proportion of unexplained variance existed
at the subject level.

Results
Treatment engagement
On average, participants completed 13.69 days (SD
= 1.92) of the 15 days of the program. Of the 191
participants, 176 (92.1%) completed the program. There
were no differences in treatment completion by sex (χ2 (1)
= 1.94, p = .163) or cohort type (χ2 (1) = 0.06, p = .815). Of

Zalta et al. BMC Psychiatry (2018) 18:242 Page 6 of 15

the 15 participants who did not complete the pro-
gram, four voluntarily withdrew from the program
seemingly due to avoidance, one withdrew due to a family
emergency, one withdrew due to perceived lack of im-
provement, seven were removed due to verbal and phys-
ical aggression, one was removed for a medical problem,
and one was removed due to failure to attend treatment
sessions.

Pre-post treatment comparison
Paired t-tests were conducted to examine changes in
symptoms from pre-treatment to post-treatment for
treatment completers (see Table 2). Analyses were con-
ducted for the entire sample and by cohort type. Results
indicated significant and large reductions in PCL-5
scores (past month d = 1.12, past week d = 1.40), PHQ-9
scores (d = 1.04), and PTCI scores (d = 0.75) from pre-
to post-treatment. For veterans in the MST cohort, effect
sizes were medium to large (d = 0.62 to 0.88) whereas ef-
fect sizes for veterans in the combat cohorts were large
to very large (d = 0.85 to 1.81). At post-treatment, 53.4%
of veterans no longer met criteria for probable PTSD
based on a past-week PCL-5 score ≤ 33 [32]. Rates of re-
mission were significantly different based on cohort type
with 62.9% of veterans treated in combat cohorts and
35.7% of veterans treated in MST cohorts no longer
meeting criteria for probable PTSD at post-treatment (χ2

(1) = 10.81, p = .001).

Trajectory of treatment response
All participants (completers and non-completers) were
included in mixed-effects regression analyses. Examin-
ation of time trends in the mixed-effects regression
models indicated that significant reductions occurred in
both PCL-5 past week and PHQ-9 scores during the
course of the treatment program (ps < .001; see Table 3). Figures 1 and 2 illustrate the general reduction in PCL-5 and PHQ-9 scores over time, respectively. The signifi- cant linear time estimates for PHQ-9 predict a 0.28 point reduction per day in depression score during the treatment program. The quadratic time trend for PCL-5 predicts an accelerating reduction over time for PTSD symptoms from .17 point in the second day to 3.78 point

daily reductions at mid-program. These effects remained
significant after adjusting for main effects of sex and co-
hort type. Neither of these covariates were significant
predictors of average PCL-5 or PHQ-9 scores.
Interactions between time and both sex and cohort

type were also examined. A significant cohort type by
time interaction was found for PTSD symptoms (p = .04)
but not for depression (p = .38), suggesting differences in
PTSD outcome time trends based on cohort type (i.e.,
combat vs. MST; see Fig. 3). Time by sex interactions
were not significant.

Changes in posttraumatic cognitions as a predictor of
changes in PTSD and depression symptoms
Posttraumatic cognitions were examined as a lagged
time-varying covariate to assess the relationship between
changes in cognitions and changes in PTSD and depres-
sion symptoms. PTCI scores were obtained the day prior
to PCL-5 and PHQ-9 score assessment, resulting in a
one-day lag. In both models, PTCI scores were a signifi-
cant predictor of subsequent PCL-5 and PHQ-9 scores.
Lagged PTCI score remained a significant predictor of
both PTSD and depression symptoms following adjust-
ment for autocorrelation using time-lagged PCL-5 or
PHQ-9 score (ps < .001; see Table 4). Estimates suggest that a 10-point reduction in PTCI score is associated with a PCL-5 decrease of 2.2 and a PHQ-9 decrease of 0.8 (see Table 4). Within-subjects and between-subjects effects of PTCI

were then disaggregated to examine whether they contrib-
uted equally to PTSD and depression outcomes [43]. Separ-
ation of these effects resulted in greater model fit for both
PCL-5 and PHQ-9 (ps < .001), suggesting invariance in the contribution of these effects. Further examination re- vealed that although both within and between-subjects effects of PTCI were significant predictors of PCL-5 and PHQ-9 scores over time (ps < .001), within-subjects re- ductions in PTCI resulted in greater decreases for both PCL-5 and PHQ-9 relative to cross-sectional between-subjects changes. Inclusion of PTCI did not alter the significance pattern

of sex, cohort type, or the sex by time interaction. How-
ever the cohort by time interaction was no longer

Table 2 Paired T-tests of Pre- and Post-Treatment Scores for Treatment Completers

Variable Total Sample Combat Cohorts MST Cohorts

n Pre-tx M (SD) Post-tx M (SD) d n Pre-tx M (SD) Post-tx M (SD) d n Pre-tx M (SD) Post-tx M (SD) d

PCL-5 month 176 57.13 (11.34) 39.78 (18.04) 1.12*** 112 57.23 (10.69) 36.94 (17.23) 1.40*** 64 56.94 (12.49) 44.77 (18.49) 0.74***

PCL-5 week 157 55.89 (11.67) 33.32 (18.48) 1.40*** 104 55.39 (11.25) 29.60 (16.35) 1.81*** 53 56.85 (12.51) 40.62 (20.30) 0.88***

PHQ-9 176 17.79 (4.88) 12.05 (5.99) 1.04*** 112 17.71 (4.59) 11.03 (5.55) 1.31*** 64 17.92 (5.39) 13.83 (6.34) 0.69***

PTCI 176 146.77 (36.05) 115.41 (46.47) 0.75*** 112 142.65 (33.25) 109.81 (43.13) 0.85*** 64 153.97 (39.74) 125.20 (50.66) 0.62***

Note. Pre-tx = Pre-treatment; Post-tx = Post-treatment. PCL-5 month = PTSD Checklist for DSM-5 scores evaluated for the past month. PCL-5 week = PTSD Checklist
for DSM-5 scores evaluated for the past week. PHQ-9 = Patient Health Questionnaire – 9. PTCI = Posttraumatic Cognitions Inventory
***p < .001

Zalta et al. BMC Psychiatry (2018) 18:242 Page 7 of 15

significant when adjusting for the PTCI. Two-way interac-
tions of sex/cohort and PTCI and three-way interactions
of sex/cohort, PTCI, and time were not significant for any
outcome. This suggests that the relationship between
changes in PTCI and symptom changes were equivalent
for men and women and for the different cohort types.
The relationships between time-varying PTCI and both
PCL-5 and PHQ-9 were also robust to adjustment for
autocorrelation (see Table 4).

Discussion

We evaluated patterns and predictors of symptom
change over the course of a 3-week co-ed cohort-based
IOP for veterans with PTSD. Consistent with previous
research on intensive outpatient programs [17], our
intervention resulted in large and clinically meaningful
changes in PTSD and depression symptoms. Our effect

size for past week PTSD symptoms (d = 1.40) was on par
with effect sizes established in efficacy trials of psycho-
therapy for PTSD (d = 1.43) [44], suggesting that inten-
sive treatment programs may lead to comparable levels
of symptom change as traditional outpatient treatment
over a much shorter timeframe (3 weeks compared to
10–12 weeks for typical outpatient treatment). More-
over, adherence and retention in our program was not-
ably high; 92% of patients completed the program and
on average, patients completed more than 13 days of the
15-day program. High rates of retention have also been
reported for other IOP programs. Beidel and colleagues
[17] reported that 89.3% of veterans completed their
IOP intervention with only 1.8% of veterans dropping

Fig. 1 PTSD symptom scores across time during treatment.
Note: Error bars represent standard errors. Day represents the day
the assessment was taken over the course of the 19 days that
participants were in the program (15 treatment days plus 4
weekend days)

Fig. 3 PTSD symptom scores across time by cohort type. Note: Error
bars represent standard errors. Day represents the day the assessment
was taken over the course of the 19 days that participants were in the
program (15 treatment days plus 4 weekend days)

Fig. 2 Depression scores across time during treatment. Note:
Error bars represent standard errors. Day represents the day the
assessment was taken over the course of the 19 days that participants
were in the program (15 treatment days plus 4 weekend days)

Table 3 Fixed Effects Parameter Estimates for Models of PTSD
and Depression Scores

Variable PCL-5 PHQ-9

b (SE) b (SE)

Time 0.03 (0.30) −0.28 (0.08)*

Time2 − 0.05 (0.01)*

Sex (male = 0) 0.08 (2.38) 0.83 (1.05)

Cohort Type (MST = 0) −0.03 (2.39) −0.32 (1.06)

Sex x Time 0.02 (0.20) −0.04 (0.08)

Cohort Type x Time −0.42 (0.20)* − 0.12 (0.08)

Note. N = 191. PCL-5 = PTSD Checklist for DSM-5 scores evaluated for the past
week. PHQ-9 = Patient Health Questionnaire – 9. Parameter estimates reflect
final outcome model estimates, which included all terms. Significance pattern
of time trends were the same when covariates were excluded, though
parameter estimates differed slightly. The quadratic time component was not
significant in models of PHQ-9, and was thus excluded from final models
*p < .05

Zalta et al. BMC Psychiatry (2018) 18:242 Page 8 of 15

out of treatment and 8.9% of veterans administratively
discharged. A recent review describing four IOP pro-
grams across the United States, including the current
program, reported that across the sites, 95% of veterans
completed IOP treatment [45]. The results from these
IOP programs compare favorably to previous research
showing that nearly 40% of veterans drop out of trad-
itional outpatient PTSD treatment programs [6]. Collect-
ively, these findings suggest that the IOP format can
lead to rapid treatment response and help to ensure that
patients receive an adequate dose of treatment. However, it
is important to note that all of these IOP programs have
been administered outside of the VA system, which may also
impact treatment adherence and response for a variety of
reasons (e.g., differences in patient population, patient ex-
pectancy, etc.). Further research is needed to compare IOP
and traditional outpatient treatment modalities in a random-
ized trial to evaluate how treatment delivery format affects
adherence and treatment outcome. Moreover, research
evaluating the implementation of similar IOP programs
within the VA system would help to determine whether this
model is equally effective within VA settings.
PTSD symptoms and depression symptoms demon-

strated different patterns of change over the course of treat-
ment. Depression symptoms demonstrated a linear decline
over the course of treatment whereas PTSD symptoms re-
vealed a quadratic pattern with little symptom change over
the first week and an acceleration in symptom reduction
over the 2nd and 3rd weeks of the program. Galovski and
colleagues [46] evaluated different patterns of symptom re-
duction over the course of a modified CPT in which the
end of treatment was determined by the patient’s individual
trajectory. They identified 3 different trajectories of PTSD
symptom change, however the trajectory in which patients
exhibited high initial symptoms and accelerating change
(i.e., patients with the same negative quadratic pattern we
observed) was the least common (7.2% of the sample). For
depression symptoms, the consistent responders (i.e. pa-
tients with the same linear reduction we observed) were
one of the more common groups (47.8% of the sample).
This may suggest that initial PTSD symptom change may

be slower in terms of number of sessions using an intensive
approach. This could be due to the time it takes to build
trust with providers or the time it takes for patients to con-
solidate the information they learn and translate that into
meaningful changes. Anecdotal evidence suggests that over
the first weekend, patients were able to digest the intensive
work that was conducted over the first week. Thus, having
brief rest periods may be beneficial for the consolidation of
gains over the course of intensive treatment. By contrast,
depression symptoms may be more liable to change early
in intensive treatment given the level of behavioral activa-
tion as part of a full-day program. It is also possible that the
initiation of an intensive program increases patients’ sense
of hope in recovery. Notably, there was no plateau in either
PTSD or depressive symptoms at the end of the treatment
program. It is possible that a longer treatment program
could lead to further symptom reduction, though poten-
tially at the cost of feasibility for patients.
Consistent with previous research in outpatient and resi-

dential samples [20, 21], changes in posttraumatic cogni-
tions predicted subsequent changes in PTSD and
depression symptoms in our IOP program. Given that CPT
directly targets maladaptive cognitions, these results sug-
gest that CPT is an important active ingredient in our inte-
grative IOP treatment, though we are unable to disentangle
the effects of the various treatment components that may
have impacted cognitions (e.g., mindfulness practice). Re-
gardless of what is driving changes in cognitions, our find-
ings clearly indicate that reductions in posttraumatic
cognitions can occur rapidly using an intensive treatment
approach and that these changes are meaningfully associ-
ated with treatment outcomes. We have shown in the same
sample of participants that pre-treatment posttraumatic
cognitions predict post-treatment suicidal ideation even
when accounting for pre-treatment suicidal ideation, PTSD
symptoms, and depression symptoms [47]. Thus, posttrau-
matic cognitions may be important indicators of treatment
response in terms of both symptoms and overall function-
ing. Future research is needed to evaluate whether
posttraumatic cognitions at post-treatment predict
long-term functional outcomes and risk for relapse.
Unexpectedly, the combat cohorts revealed a greater re-

duction in PTSD symptoms over time relative to MST co-
horts reflecting an approximate 10-point difference in
PTSD symptoms between combat and MST cohorts at
treatment endpoint. These findings are inconsistent with
previous research showing that MST status did not predict
treatment response across several VA intensive PTSD treat-
ment programs [12, 18]. There are several potential expla-
nations that could help to account for these discrepancies.
All of the treatments offered at the VA were delivered over
longer time period. One possibility is that individuals with
MST may not respond as well to treatment over a short-
ened timeframe. Individuals with MST may have higher

Table 4 Parameter Estimates for PTCI as a Lagged Predictor of
PTSD and Depression Scores

Lagged PTCI model variable PCL-5 PHQ-9

b(SE) b(SE)

PTCI as time-varying covariate 0.22 (0.01)* 0.08 (0.01)*

PTCI disaggregated Within-Subjects 0.32 (0.02)* 0.10 (0.01)*

PTCI disaggregated Between-Subjects 0.21 (0.02)* 0.05 (0.01)*

PTCI adjusting for autocorrelation 0.19 (0.02)* 0.05 (0.01)*

Autocorrelation 0.46 (0.04)* 0.46 (0.04)*

Notes. N = 188. Parameter estimates reflect final outcome model estimates,
which included time (as previously characterized), sex, and cohort type
*p < .05

Zalta et al. BMC Psychiatry (2018) 18:242 Page 9 of 15

rates of interpersonal trauma in childhood [48, 49], which
could contribute to more entrenched posttraumatic cogni-
tions that are more difficult to change for individuals with
MST compared to those with combat trauma [50]. Notably,
the cohort by time interaction was no longer significant
after adding posttraumatic cognitions to the model. This
may suggest that differences in posttraumatic cogni-
tions across the cohorts drove differences in treat-
ment response; however, it is also possible that this
variable became non-significant due to issues of stat-
istical power. Another possibility is that differences in
group dynamics affected the cohorts differently. Anec-
dotally, clinicians reported a larger number of interpersonal
issues that arose over the course of group treatment in
MST cohorts relative to combat cohorts, which delayed
treatment progress. Specifically, interpersonal conflicts
among group members in MST cohorts sometimes in-
terfered with the delivery of the CPT group content. It is
possible that a greater focus on distress tolerance and
interpersonal effectiveness skills early in the IOP program
may be beneficial for individuals with MST. Despite the
differences across the MST and combat cohorts, it is im-
portant to recognize that individuals in the MST cohorts
revealed large and clinically meaningful symptom reduc-
tions, suggesting that an intensive treatment approach is
promising for producing large and rapid symptom reduc-
tions for individuals with MST.
Consistent with what has been demonstrated in

other intensive PTSD programs [16, 17] as well as
traditional outpatient treatment [44], many patients were
still symptomatic and did not reach remission at treat-
ment endpoint. These findings may be indicative of sev-
eral things. First, it is possible that these results are
affected by our measurement approach in conjunction
with an intensive delivery format. PTSD symptoms are
typically assessed over the past month; at treatment end-
point, this would include the time period before the vet-
eran even started treatment. We attempted to correct for
this by assessing past week PTSD symptoms and the effect
sizes for past week symptoms were notably higher. How-
ever, even a past week assessment would mean that vet-
erans would have to account for symptoms occurring
before one-third of the treatment was delivered. It is pos-
sible that veterans will continue to experience symptom
reduction following the IOP treatment without further
intervention as they apply newly acquired skills in their
home environment and become more confident in their
treatment gains. Our findings may also suggest that for
many patients, IOP programs can help to stimulate initial
symptom reduction, but further outpatient treatment may
be needed to achieve remission. Finally, it is also possible
that these findings suggest that there may be ways of opti-
mizing our treatment approach to improve outcomes even
further, particularly for veterans with MST as their index

trauma. For example, booster sessions using telehealth
may be indicated.
Our treatment approach is unique in conducting co-ed

treatment cohorts; the vast majority of research on inten-
sive treatment for veterans has been done exclusively on
single sex groups [11–14]. Although the cohorts were im-
balanced with a higher proportion of women in the MST
cohorts and a higher proportion of men in the combat co-
horts, our findings indicate that male and female veterans
benefitted similarly from the IOP. Given the small sample
of men with MST, we did not have sufficient power to
evaluate whether interactions between sex and MST status
predicted treatment response. However, our findings provide
preliminary evidence that co-ed cohorts based on trauma
type are tolerable and effective for veterans with PTSD.
Several limitations should be taken into consideration

when interpreting our results. Because all measures were
conducted as part of routine clinical practice, we relied on
the use of self-report measures (PCL-5, PHQ-9) as our
primary treatment outcomes, rather than gold-standard
clinician administered measures such as the CAPS-5. As
is typical in effectiveness research, we also did not have a
control group in this study. Therefore, we cannot
evaluate the degree to which changes over time were
due to non-specific treatment components (e.g., thera-
peutic alliance) versus specific treatment components
(e.g., the use of cognitive restructuring techniques).
Although all IOP clinicians were CPT trained and
received on-site consultation during the IOP, we did
not conduct formal treatment fidelity ratings; there-
fore, we cannot empirically establish the degree to
which the CPT protocol was followed. Moreover, our
treatment approach was multifaceted with the integra-
tion of trauma-focused treatment, wellness, psychoeduca-
tion, and case management. We are unable to determine
which of these treatment components are necessary for
treatment outcomes.

Conclusions

This study is the first to evaluate patterns and predictors
of symptom change over the course of an intensive out-
patient PTSD treatment for veterans. This study suggests
that IOPs show great promise in delivering full doses of
evidence-based treatment and producing rapid and clinic-
ally meaningful symptom reduction for different types of
veterans including men and women as well as combat and
MST trauma survivors. Moreover, our findings suggest
that reductions in posttraumatic cognitions may be a key
treatment target in CPT-based intensive programs. Given
that large amount of subject-level variance observed, more
research is needed to determine which factors impact
treatment outcomes in this intensive treatment approach
to help improve treatment selection and effectiveness.

Zalta et al. BMC Psychiatry (2018) 18:242 Page 10 of 15

Appendix A
Table 5 CPT Session Outlines

Day Group CPT Session Content Individual CPT Session Content Homework

Pre-IOP N/A • Call client
• Introductions
• Program overview
• Cognitive Processing Therapy
○ 15 daily sessions
○ Trauma-focused
○ Can initially be challenging but we have found it to
help with symptom reductions

• Questions?
• Motivation for treatment
• Barriers
• Needed support
• Check-in about reactions to call

• Call therapist if questions
come up

Week 1
Monday

N/A • Set agenda, make introductions and explain check-in
process

• PTSD symptoms
○ Intrusions
○ Avoidance
○ Negative alterations in cognitions and mood
○ Hyperarousal

• Trauma recovery and Fight-Flight-Freeze response
• Cognitive theory
• Role of emotions in trauma recovery
• Brief review of most traumatic event
• Therapy rationale – stuck points
• Anticipating avoidance and increasing compliance
• Overview of treatment – structured
• Discuss group readiness

• Check-in about reactions to session

• Write Impact Statement

Week 1
Tuesday

• Agenda, introductions, and check-ins
• Group rules
• Provide treatment rationale
○ Cognitive theory
○ Types of emotions
○ Biological basis of PTSD

• Not everyone responds to trauma the same
• Importance of support among group
members

• First Impact Statement
• Reminder: Impact Statement assignment
and problem solve completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda

• Patient to read Impact Statement
• Discuss meaning of Impact Statement
• Describe stuck points more fully
• Identify stuck points & generate Stuck Point Log
• Examine connections among events, thoughts, and
feelings

• Introduce ABC Worksheets
• Check-in about reactions to session

• Complete 3 ABC
Worksheets focused on
assimilated stuck points

Week 1
Wednesday

• Agenda and check-ins
• Share Impact Statements
• Introduce connections between events,
thoughts, and feelings

• Reminder: ABC Worksheet assignment and
problem solve completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review ABC Worksheets, further differentiating between
thoughts and feelings

• Use Socratic questioning on ABC worksheets related to
the index event to help patient identify alternative
hypotheses

• Continue to add to Stuck Point Log
• Check-in about reactions to session

• Complete 3 ABC
Worksheets focused on
assimilated stuck points

• Write first Trauma Account

Week 1
Thursday

• Agenda and check-ins
• Continue to share Impact Statements
• Discuss ABC Worksheets
• Introduce Socratic questioning in group,
practice challenging assimilated stuck
points
○ Up to two patients share

• Reminder: ABC Worksheet assignment,
Trauma Account assignment, and problem
solve completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Patient to read full Trauma Account aloud with affective
expression

• Identification of stuck points
• Use Socratic questioning to challenge assimilated stuck
points

• Explain difference between responsibility and blame
• Continue to add to Stuck Point Log
• Check-in about reactions to session

• Complete 3 ABC
Worksheets focused on
assimilated stuck points

• Write second Trauma
Account

Week 1
Friday

• Agenda and check-ins
• Share thoughts and feelings about writing

• Brief check-in
• Complete practice assignment review and set agenda

• Complete 3 Challenging
Questions Worksheet

Zalta et al. BMC Psychiatry (2018) 18:242 Page 11 of 15

Table 5 CPT Session Outlines (Continued)

Day Group CPT Session Content Individual CPT Session Content Homework

Trauma Account

• Practice challenging assimilated stuck
points
○ Up to two patients share

• Reminder: ABC Worksheet assignment,
Trauma Account assignment, and problem
solve completion
• Check-in about reactions to session

• Patient to read full Trauma Account aloud with affective
expression; help identify differences between first and
second account

• Introduce Challenging Questions Worksheet
• Use Socratic questioning to challenge assimilated stuck
points

• Check-in about reactions to session

Week 2
Monday

• Agenda and check-ins
• Discuss re-writing Trauma Account
• Assess for and normalize strong emotions
at this phase of therapy

• Practice challenging assimilated stuck
points
○ Up to two patients share

• Reminder: Challenging Questions
Worksheet assignment and problem solve
completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review Challenging Questions Worksheet
○ Focus on assimilated stuck points

• Continue cognitive therapy for stuck points
• Introduce Patterns of Problematic Thinking Worksheet
• Check-in about reactions to session

• Complete 1 Patterns of
Problematic Thinking
Worksheet

Week 2
Tuesday

• Agenda and check-ins
• Practice challenging assimilated stuck
points
○ Up to two patients share

• Reminder: Patterns of Problematic Thinking
Worksheet assignment and problem solve
completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review Patterns of Problematic Thinking Worksheet
○ Complete challenging Questions if patient is still
struggling with content

• Continue cognitive therapy for stuck points
• Introduce Challenging Beliefs Worksheets
• Introduce first of five problem areas: Safety
• Check-in about reactions to session

• Complete 3 Challenging
Beliefs Worksheets

• Review Safety Module

Week 2
Wednesday

• Agenda and check-ins
• Practice challenging assimilated stuck
points
○ Up to two patients share

• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion

• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining assimilated stuck points or Safety
stuck points

• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Challenging Beliefs Worksheets
• Introduce second of five problem areas: Trust
• Check-in about reactions to session

• Complete 3 Challenging
Beliefs Worksheets

• Review Trust Module

Week 2
Thursday

• Agenda and check-ins
• Practice challenging assimilated stuck
points
○ Up to two patients share
• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion
• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining assimilated stuck points or Trust
stuck points

• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Challenging Beliefs Worksheets
• Introduce third of five problem areas: Power/Control
• Check-in about reactions to session

• Complete 3 Challenging
Beliefs Worksheets

• Review Power / Control
Module

Week 2
Friday

• Agenda and check-ins
• Practice challenging assimilated/over-
accommodated stuck points
○ Up to two patients share

• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion
• Check-in about reactions to session

• Brief check-in
• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining assimilated stuck points or

Power/Control stuck points

• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Challenging Beliefs Worksheets
• Introduce fourth of five problem areas: Esteem
• Check-in about reactions to session

• Complete 3 Challenging
Beliefs Worksheets

• Review Esteem Module

Week 3
Monday

• Agenda and check-ins
• Practice challenging assimilated/over-
accommodated stuck points
○ Up to two patients share
• Brief check-in
• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining assimilated stuck points or
• Complete 3 Challenging
Beliefs Worksheets

• Review Intimacy Module

Zalta et al. BMC Psychiatry (2018) 18:242 Page 12 of 15

Endnotes
1Quadratic time effects were non-significant for both

PCL and PHQ outcomes when including lagged time-
varying PTCI as a covariate, and were thus excluded from
model estimates.

2To examine clustering by cohort, three-level mixed
models were also examined. However, because trends
and significance patterns for time and covariates of
interest were nearly identical, and due to our interest in
including cohort type (MST and combat), only two-level
models were reported here.

Acknowledgements

We would like to thank the participating veterans and their families. We also
wish to acknowledge Walter Faig for preparing the dataset for analysis as
well as the Road Home Program administrators, research assistants, and
clinicians for their contributions to this work.

Funding

We thank the Wounded Warrior Project for their support of the Road Home
Program and the resulting research. AKZ’s effort is partially supported by a
career development award from the National Institute of Mental Health (K23
MH103394). NSK’s effort is partially supported by the National Center for
Advancing Translational Science of the National Institutes of Health (UL1
TR002389). The content is solely the responsibility of the authors and does

Table 5 CPT Session Outlines (Continued)
Day Group CPT Session Content Individual CPT Session Content Homework

○ Focus on trauma themes
• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion

• Check-in about reactions to session

Esteem stuck points
• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Challenging Beliefs Worksheets
• Introduce fifth of five problem areas: Intimacy
• Initiate contact with community provider in patient’s
area

• Check-in about reactions to session

Week 3
Tuesday

• Agenda and check-ins
• Practice challenging assimilated/over-
accommodated stuck points
○ Up to two patients share
○ Focus on trauma themes

• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion
• Check-in about reactions to session

• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining stuck points

• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Challenging Beliefs Worksheets

• Continue to establish contact with community provider
in patient’s area

• Check-in about reactions to session
• Complete 3 Challenging
Beliefs Worksheets

Week 3
Wednesday

• Agenda and check-ins
• Practice challenging assimilated/over-
accommodated stuck points
○ Up to two patients share
○ Focus on trauma themes
• Reminder: Challenging Beliefs Worksheet
assignment and problem solve completion
• Check-in about reactions to session
• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining stuck points
• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Assign Final Impact Statement
• Continue to establish contact with community provider
in patient’s area

• Check-in about reactions to session

• Final Impact Statement

Week 3
Thursday

• Agenda and check-ins
• Discuss Final Impact Statement
• Involve patients in reviewing the course of
treatment and patient’s progress

• Help identify goals for the future and
delineate strategies for meeting them

• Check-in about reactions to session/
program

• Complete practice assignment review and set agenda
• Review Challenging Beliefs Worksheet
○ Address remaining stuck points
• Help patient confront problematic cognitions and
generate alternative beliefs using the Challenging
Beliefs Worksheet

• Patient to read Final Impact Statement
• Involve patient in reviewing the course of treatment
and patient’s progress

• Help identify goals for the future and delineate
strategies for meeting them

• Continue to establish contact with community provider
in patient’s area
• Check-in about reactions to session

N/A

Week 3
Friday

N/A – Graduation • Review course of treatment and patient progress
• Go over discharge plan
• Assess patient goals for the future
• Continue to establish contact with community provider
in patient’s area

• Review referrals and plan for aftercare

N/A – Graduation

Zalta et al. BMC Psychiatry (2018) 18:242 Page 13 of 15

not necessarily represent the official views of the National Institutes of Health
or Wounded Warrior Project.

Availability of data and materials

The datasets generated and analyzed during the current study are not
publicly available because they contain more than two indirect identifiers of
human research participants that cannot be sufficiently anonymized for a
public repository. The datasets are available from the corresponding author
on reasonable request.

Authors’ contributions

AKZ was involved in the development of the treatment program, acquisition
of the data, data analysis, interpretation of the data, and drafting the
manuscript. PH was involved in the development of the treatment program,
treatment delivery, acquisition of the data, data analysis, interpretation of the
data, and drafting of the manuscript. DLS was involved in data analysis, and
drafting the manuscript. BJK, AML, PSN, MBB, TSR, and NSK were involved in
the development of the treatment program, treatment delivery,
interpretation of the data, and drafting the manuscript. RAB was involved in
the acquisition of the data, data analysis, and drafting the manuscript. MHP
was involved in establishing the treatment clinic, interpretation of the data,
and editing the manuscript. All authors read and approved the final
manuscript.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at Rush University
Medical Center. A waiver of consent was obtained because all assessments
were collected as part of routine care procedures.

Consent for publication

Not applicable.

Competing interests

AKZ receives grant support from the National Institute of Mental Health and
the Brain & Behavior Research Foundation. PH receives grant support from
the Boeing Company and the American Psychological Association. MHP
receives research funding from National Institutes of Health and Janssen
Pharmaceuticals; he provides consultation to Aptinyx, Clintara, and Palo Alto
Health Sciences; he has equity in Argus, Doyen Medical, Mensante
Corporation, Mindsite, and Targia Pharmaceuticals; he receives royalties from
SIGH-A, SAFER interviews. NSK receives grant support from Welcome Back
Veterans, an initiative of the McCormick Foundation and Major League Base-
ball; the Bob Woodruff Foundation; the Substance Use & Mental Health Ser-
vices Administration; the National Institute on Drug Abuse; and the National
Center for Advancing Translational Science of the National Institutes of
Health. All other authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Author details

1Rush University Medical Center, Chicago, IL 60612, USA. 2University of
California, Irvine, Irvine, CA 92697, USA. 3Olivet Nazarene University,
Bourbonnais, IL 60914, USA.

Received: 15 January 2018 Accepted: 11 July 2018

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http://www.ptsd.va.gov/public/materials/apps/mobileapp_mindfulness_coach.asp

http://www.ptsd.va.gov/public/materials/apps/mobileapp_mindfulness_coach.asp

http://www.ptsd.va.gov/public/materials/apps/mobileapp_mindfulness_coach.asp

https://www.headspace.com/headspace-meditation-app

https://www.headspace.com/headspace-meditation-app

http://www.ptsd.va.gov

http://www.qualtrics.com

http://www.ptsd.va.gov

https://doi.org/10.1007/s10608-018-9925-6

https://doi.org/10.1007/s10608-018-9925-6

Abstract
Background
Method
Results
Conclusion
Background
Method
Intervention
Cognitive processing therapy
Mindfulness based resiliency training
Participants
Assessment procedures
Measures
Demographics
Posttraumatic stress disorder
Depression
Posttraumatic cognitions
Analytic approach for trajectory analysis
Results
Treatment engagement
Pre-post treatment comparison
Trajectory of treatment response
Changes in posttraumatic cognitions as a predictor of changes in PTSD and depression symptoms
Discussion
Conclusions
• show [App1]
• Quadratic time effects were non-significant for both PCL and PHQ outcomes when including lagged time-varying PTCI as a covariate, and were thus excluded from model estimates.

Acknowledgements
Funding
Availability of data and materials
Authors’ contributions
Ethics approval and consent to participate
Consent for publication
Competing interests
Publisher’s Note
Author details
References

ORIGINAL RESEARCH
published: 01 March 2019

doi: 10.3389/fpsyt.2019.00062

Frontiers in Psychiatry | www.frontiersin.org 1 March 2019 | Volume 10 | Article 62

Edited by:

Rafael Christophe Freire,

Universidade Federal do Rio de

Janeiro, Brazil

Reviewed by:

William Berger,

Universidade Federal do Rio de
Janeiro, Brazil

Helga Rodrigues Rodrigues,

Universidade Federal do Rio de
Janeiro, Brazil

Fiammetta Cosci,

Università degli Studi di Firenze, Italy

*Correspondence:

Ashley N. Clausen

ashley.n.clausen@gmail.com

Specialty section:

This article was submitted to

Mood and Anxiety Disorders,

a section of the journal

Frontiers in Psychiatry

Received: 26 November 2018

Accepted: 28 January 2019

Published: 01 March 2019

Citation:

Clausen AN, Thelen J, Francisco AJ,

Bruce J, Martin L, McDowd J and

Aupperle RL (2019) Computer-Based

Executive Function Training for

Combat Veterans With PTSD: A Pilot

Clinical Trial Assessing Feasibility and

Predictors of Dropout.

Front. Psychiatry 10:62.

doi: 10.3389/fpsyt.2019.00062

Computer-Based Executive Function
Training for Combat Veterans With
PTSD: A Pilot Clinical Trial Assessing
Feasibility and Predictors of Dropout
Ashley N. Clausen1,2,3*, Joan Thelen4, Alex J. Francisco4, Jared Bruce5, Laura Martin5,

Joan McDowd4 and Robin L. Aupperle3,4,6

1 VA Mid-Atlantic MIRECC, Durham VA Medical Center, Durham VA, Durham, NC, United States, 2 Duke University Medical

Center, Brain Imaging and Analysis Center, Duke University, Durham, NC, United States, 3 Laureate Institute for Brain

Research, Tulsa, OK, United States, 4 Department of Psychology, University of Missouri-Kansas City, Kansas City, MO,

United States, 5 Department of Preventative Medicine and Public Health, University of Kansas Medical Center, Kansas City,

KS, United States, 6 Department of Community Medicine, University of Tulsa, Tulsa, OK, United States

Background: While evidence-based PTSD treatments are often efficacious, 20–50%

of individuals continue to experience significant symptoms following treatment. Further,

these treatments do not directly target associated neuropsychological deficits. Here,

we describe the methods and feasibility for computer-based executive function training

(EFT), a potential alternative or adjunctive PTSD treatment.

Methods: Male combat veterans with full or partial PTSD (n = 20) and combat-exposed

controls (used for normative comparison; n = 20) completed clinical, neuropsychological

and functional neuroimaging assessments. Those with PTSD were assigned to EFT

(n = 13) or placebo training (word games; n = 7) at home for 6 weeks, followed by repeat

assessment. Baseline predictors of treatment completion were explored using logistic

regressions. Individual feedback and changes in clinical symptoms, neuropsychological

function, and neural activation patterns are described.

Results: Dropout rates for EFT and placebo training were 38.5 and 57.1%, respectively.

Baseline clinical severity and brain activation (i.e., prefrontal-insula-amygdala networks)

during an emotional anticipation task were predictive of treatment completion. Decreases

in clinical symptoms were observed following treatment in both groups. EFT participants

improved on training tasks but not on traditional neuropsychological assessments. All

training completers indicated liking EFT, and indicated they would engage in EFT (alone

or as adjunctive treatment) if offered.

Conclusion: Results provide an initial framework to explore the feasibility of

placebo-controlled, computerized, home-based executive function training (EFT) on

psychological and neuropsychological function and brain activation in combat veterans

with PTSD. Clinical severity and neural reactivity to emotional stimuli may indicate which

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Clausen et al. Executive Function Training and PTSD

veterans will complete home-based computerized interventions. While EFT may serve

as a potential alternative or adjunctive PTSD treatment, further research is warranted

to address compliance and determine whether EFT may benefit functioning above and

beyond placebo interventions.

Keywords: cognitive training, posttraumatic stress, executive function, fMRI, neuropsychological, cognitive

inhibition, trauma treatment, placebo-controlled trial

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a debilitating trauma-
related disorder encompassing psychological and cognitive
complaints (1, 2). PTSD is highly comorbid with other
psychological problems including depression, substance use (2),
and suicidal ideation (3). After the onset of Operation Iraqi
Freedom (OIF) in 2003, the prevalence of combat-related PTSD
rose dramatically from 2–3 to 23% (4, 5), highlighting the need to
identify effective PTSD treatments.

Currently, the Veteran’s Health Administration is
disseminating two evidence-based psychological treatments
for PTSD, including Prolonged Exposure (6) and Cognitive
Processing Therapy (7). Despite empirical support, only 23–40%
of veterans seek out psychological treatment (8). Of those who
do engage in treatment, up to 60% continue to experience
clinically significant symptoms (9). Further, evidence-based
PTSD treatments do not directly target related cognitive and
neuropsychological deficits including alterations in processing
speed, executive functions, and verbal memory (1, 10).

Executive functions, including cognitive inhibition and
attention regulation, are thought to be particularly important for
emotional regulation in the context of PTSD (1, 11). Observed
biases toward trauma-relevant stimuli and the hyperarousal
symptoms of PTSD may partially stem from deficits in inhibition,
disengagement and attentional control (1). Individuals with
PTSD exhibit dysfunction in overlapping regions of the
prefrontal cortex (PFC) during both emotional and executive
function tasks, including the rostral anterior cingulate cortex
(ACC) and dorsolateral PFC (1, 10). Propensity to recruit these
regions relates to neuropsychological performance (12) and
likelihood of treatment response (13). Therefore, treatments
targeting executive functions and underlying neural processes
may not only improve neuropsychological performance, but also
beneficially impact psychological symptoms of PTSD.

Interference control training, training attention or working
memory in the context of affective stimuli, is one such treatment
that targets inhibitory processes, and has shown promise. In
sexual assault survivors with PTSD, interference control training
was associated with improved cognitive performance post-
training, compared to those in a control training, and both
trainings were associated with reduced PTSD symptoms (14).
Similarly, in veteran populations, attentional control training
(balance of attention toward threat and neutral stimuli) related
to reductions in attention bias variability compared to attention
bias modification training (directing attention away from threat);
however, both trainings were associated with PTSD symptom
reduction (15). While it holds promise as a PTSD intervention,

it is unknown if cognitive training (e.g., interference control or
attentional control training) is associated with improvements
in overall executive or neuropsychological functioning or if
broader-based executive control training would have similar or
additional beneficial effects.

Another strategy is to target a range of executive functions
and underlying neural processes using computer-based executive
function training (EFT). Growing literature supports the
potential utility of EFT with clinical populations. In depression,
computer-based EFT combined with social skills training and
group activities has been associated with improvements in
memory encoding and retention compared to waitlist (16,
17). Computer-based EFT targeting visual, auditory, and cross-
modality tasks was associated with decreases in depressive
symptoms and increases in global executive control and attention
(18). Additionally, training in selective attention and working
memory led to greater decreases in depressive symptoms,
rumination, decreased amygdala reactivity during emotional
processing and increased dlPFC activity during working memory
compared to treatment as usual (19). While EFT has shown some
promise, placebo-controlled trials have not yet been conducted.
Further, the feasibility and benefit for individuals with PTSD are
less understood.

The present pilot study utilized a placebo-controlled design
to determine the feasibility and acceptability of home-based,
computerized EFT for combat veterans with PTSD. Given higher
than expected dropout, we specifically examined predictors of
treatment completion. In addition, we explored the potential
effects of training on PTSD symptoms, neuropsychological
performance, and neural activation during both emotional and
cognitive processing paradigms. We expected EFT to be well-
accepted and easily completed by veterans, and to result in
improved clinical symptoms, neuropsychological function, and
increased ACC and dorsolateral PFC activation during emotional
and cognitive processing.

METHODS

Participants
Participants were recruited from a community sample between
August 2012 and June 2014 and included 52 male combat
veterans who served since OIF. Participants were recruited via
advertisements in the general community (i.e., radio, newspaper,
and Facebook) and on local college campuses (i.e., via emails,
flyers, etc.), and by providing informational flyers to clinicians
at local VA hospitals. Veterans were excluded from the current
study if they endorsed a psychological disorder other than PTSD

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Clausen et al. Executive Function Training and PTSD

FIGURE 1 | CONSORT diagram showing the flow of recruitment and retention for the present study. Interested veterans completed a phone screen to determine

initial eligibility for the baseline behavioral assessment. Veterans were then assigned to either the combat-exposed control group (those without a current mental health

disorder) or those with post-traumatic stress disorder (PTSD). Those with PTSD were assigned to 6-weeks of either executive function or active placebo training.

as the primary cause for distress, current substance or alcohol
use disorder, schizophrenia or bipolar disorder [determined via
the Mini International Neuropsychiatric Inventory (20)], medical
conditions affecting the hemodynamic response, current use of
opioid’s, benzodiazepines and/or thyroid medications, history of
moderate to severe head injury (loss of consciousness >30 min,
or post-traumatic amnesia lasting >24 h) or neurological
disorder, or metal or devices contraindicated for fMRI. Veterans
taking a stable dose (>6 weeks) of antidepressants or sleep
medication were included. Two PTSD participants and one
combat-exposed control participant reported taking a stable dose
of antidepressants at baseline and denied changes in medication
during treatment and at follow-up. Twenty veterans (n = 14 with
PTSD) endorsed history of mild TBI.

Following baseline assessment, two veterans did not meet
study criteria and eight withdrew prior to completing the

neuroanatomical assessment. Forty-two veterans, 21 with
PTSD, and 21 without PTSD, completed the neuroanatomical
assessment (described below). However, one MRI scan was
excluded from the combat-exposed control group as it did not
pass quality assurance (see Figure 1 for CONSORT diagram,
and Table 1 for descriptive statistics). In addition, one veteran
was excluded from analyses of the multisource interference task
(MSIT) conducted during fMRI because of loss of behavioral
data during that task due to equipment failure. A second
veteran was excluded from neuroimaging analyses due to
a lesion identified in radiologic review within a region of
interest (ACC).

This study was approved by the University of Missouri–
Kansas City and University of Kansas Medical Center
Institutional Review Boards. All participants provided
written informed consent. The present study is registered

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Clausen et al. Executive Function Training and PTSD

TABLE 1 | Descriptive statistics at baseline.

EFT group

(n = 14)

Placebo

group (n = 6)

Combat-exposed

controls (n = 20)

Mean (SD) Mean (SD) Mean (SD)

Age 32.6 (6.9) 36.7 (6.8) 30.7 (7.6)

Years of education 14.1 (2.0) 13.2 (0.8) 14.8 (1.9)

Tobacco use (% using

tobacco)

46.4% 83.33% 70.0%

CAPS total score 55.0 (21.7) 61.3 (20.3) 13.4 (9.2)

PTSD symptom checklist

total score

46.4 (13.0) 48.7 (15.6) 25.5 (6.9)

Depressive symptoms 16.9 (10.3) 14.3 (6.1) 6.8 (6.3)

Neurobehavioral

symptoms

26.8 (13.0) 22.2 (10.3) 10.6 (7.5)

Impulsivity 20.1 (6.0) 22.2 (7.7) 20.8 (5.0)

Executive functioning 0.1 (0.6) 0.3 (0.2) 0.2 (0.4)

NP functioning 0.1 (0.4) 0.3 (0.3) 0.2 (0.4)

PSYCHOLOGICAL DIAGNOSES (% ENDORSED)

Major depressive disorder,

lifetime

50.0% 50.0% 30.0%

Obsessive compulsive

disorder

7.1% 0% 0.0%

Agoraphobia 50.0% 16.7% 0.5%

PTSD (full criteria) 85.7% 53.3% 0.0%

Generalized anxiety

disorder

0% 0% 20.0%

Antisocial personality

disorder
7.1% 0% 0.0%

EFT, executive functioning training; CAPS, clinician administered PTSD scale-IV;

NP, neuropsychological; Tobacco use included current use of smokeless tobacco

and cigarettes.

with ClinicalTrials.gov (NCT01644851). Baseline data from
overlapping samples has been previously published (21–23).

Psychological Assessment
All veterans completed baseline assessments. Veterans who
completed EFT and placebo training were also assessed post-
treatment. The Mini International Neuropsychiatric Inventory
for DSM-IV (20) was administered to assess Axis-I disorders.
Current PTSD diagnosis and severity were assessed using the
Clinician Administered PTSD Scale (CAPS)—IV (24). Twelve
veterans met full criteria and four met partial criteria for PTSD,
which was determined as missing one symptom from clusters
C or D (see Supplementary Material for scoring criteria).
Veterans also completed the PTSD symptom checklist (PCL)—
Military version (25), Beck Depression Inventory (BDI)—II
(26), Neurobehavioral Symptom Inventory [NSI (27)], and
Sensation Seeking Scale [SSS (28)]. All measures showed
adequate to excellent internal consistency in the present sample
(αCAPS =0.92, αPCL =0.95, αBDI =0.88, αNSI =0.89,
αSSS =0.77). A 10-item post-treatment questionnaire was
created to assess acceptability of the treatment protocol. This
questionnaire included questions relating to the intervention
delivery method, how interesting and beneficial they felt training

was, and whether they would engage in the training if offered
by clinics (see Supplementary Material for full wording of
this questionnaire).

Neuropsychological Assessment
Neuropsychological assessment included the Delis-Kaplan
Executive Function System Color-Word Interference Test
(inhibition and flexibility), Tower Test [planning, rule learning,
and inhibition (29)], Symbol Digit Modalities Test [visual
scanning, perceptual speed, motor speed, and memory
(30)], Auditory Verbal Learning Test [verbal learning and
memory (31)], Trail Making Test [visual scanning, sequencing,
switching and motor speed (32, 33)], and Neuropsychological
Assessment Battery Digits [verbal attention (34)]. Z-scores for
each test were averaged to obtain an overall mean score for
neuropsychological performance. A second composite score
was created for executive function related performance. To
limit the impact of practice effects on neuropsychological
tasks, alternative forms were given, when available, for the
post-treatment assessment (see Supplementary Material for
full neuropsychological administration and scoring procedures).
Those who completed training repeated neuropsychological
assessment post-treatment.

fMRI Procedures
Scanning was conducted on a Siemens 3.0 Tesla Skyra
MRI scanner. A T1-weighted anatomical scan was acquired
using a 3D MPRAGE sequence (TR/TE = 2,300/2 ms, flip
angle = 8◦, FOV = 256 mm, matrix = 256 × 256, 1 mm
slices). To assess prefrontal activation in relationship to PTSD
during emotional and cognitive tasks, veterans completed the
Multisource Interference task [MSIT (35, 36)] and the emotional
cued anticipation task (12, 37, 38) during the scan, which were
conducted similarly to prior studies. Briefly, the MSIT was
developed specifically to assess cognitive inhibition [fMRI (35)].
The MSIT involves presentation of three digits and participants
are instructed to identify the target digit that differs from the
rest, using a button box. In congruent trails, the target location
matches button position (e.g., XX3); for incongruent conditions,
the target location does not match button position, requiring
inhibition of the response to the number location (e.g., 311).
Veteran’s also completed an emotional cued anticipation task
(12, 37), which combines a continuous performance task (CPT)
with the interspersed presentation of affective visual stimuli.
Participants are instructed 1) to press a button corresponding
to the direction of an arrow on the screen and 2) that when the
background screen turns blue, accompanied by a 250-Hz tone, a
positive image will soon appear (positive anticipation); whereas,
when the background turns yellow, accompanied by a 1,000 Hz
tone, a negative image will appear (negative anticipation).
Anticipation periods last 6 s, image presentation lasts 2 s, and
the baseline CPT task is interspersed for variable duration
averaging 8 s. Total task duration is 580 s. Response accuracy and
reaction times are obtained for the CPT during baseline and the
anticipation periods.

Each task was conducted during one gradient echo BOLD scan
(35/43 axial slices for MSIT/anticipation; TR/TE = 2,000/25 ms,

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Clausen et al. Executive Function Training and PTSD

flip angle = 90◦, FOV = 220 mm, matrix = 80 × 80,
slice = 3.5 mm, 5 skip; 326/290 volumes for MSIT/anticipation).
EPI scans were aligned to anatomical scans, volume registered,
and corrected for slice timing and motion. For both tasks, the
multiple regression models included the following regressors
of no interest: residual motion (roll, pitch, and yaw), white
matter mask to control for physiological noise, and baseline
and linear trends. Regressors of interest included congruent
and incongruent trials for the MSIT task and negative (NA)
and positive (PA) anticipation periods, and negative and
positive image presentation (analyses focused on anticipation
periods) for the anticipation task. For both tasks, percent
signal change (PSC) was calculated by dividing the regressor
of interest by the baseline, and data were spatially blurred,
normalized to Talairach space, and resampled to 4 mm3. PSC
was extracted for the following regions of interest (ROI’s):
bilateral insula, amygdala, and dorsal midfrontal cortex, as well
as dorsal, ventral, and rostral aspects of the ACC (Figure S1).
More details on fMRI ROI construction are included in the
Supplementary Material.

Computer-Based Interventions
Veterans with partial or full PTSD (n = 21) received EFT
or placebo training. One veteran withdrew from the study
prior to training onset. Therefore, a total of 20 veterans were
allocated to treatment (see Figure 1 for CONSORT diagram).
The first 13 veterans were randomly assigned by a lab manager
using a block random allocation sequence in groups of three
(stratified by comorbid depression and/or TBI), created by
a co-investigator (JB). All other research staff, including
those administering psychodiagnostic and neuropsychological
assessments were blind to the sequence of allocation until
the study ended. Given compliance issues in combination
with early study termination (due to the PI, RLA, moving
institutions), the last seven veterans were assigned to EFT to
optimize collection of feasibility and acceptability data. Veterans
in both conditions completed daily, in-home computerized
training and weekly phone check-ins to assess clinical
symptoms and troubleshoot training obstacles (e.g., motivation,
technical difficulties).

Executive Function Training
EFT was delivered using LumosityTM (lumosity.com), which
offers training tasks specifically related to executive functions that
are based on traditional neuropsychological measures, visually
engaging, and increased difficulty based on performance. The
combination of tasks included in the present study provided
training in the following aspects of executive functioning:
response inhibition, attentional and task switching, working
memory, and processing speed. Veterans were given access to
free Lumosity accounts for the purposes of this study. Similar to
protocols in other populations (39, 40), training was completed
∼30-min per day, five times per week, for six weeks, and
involved 60 sessions, 560 games, and an estimated 900 training
minutes. Tasks were completed in the same order for each veteran
and included the following: Color Match, Lost in Migration,
Brain Shift, Brain Shift Overdrive, Speed Match, Memory Match,

Memory Match Overload, Penguin Pursuit, and Disillusion [see
(41) and Supplementary Material].

Placebo Word-Game Training
Placebo training involved word searches, hangman puzzles, and
crosswords administered on a website created for this study. This
training provided a relatively well-matched placebo condition
due to involving (1) the same frequency/duration of computer-
based training as EFT, (2) cognitively active tasks, (3) a plausible
intervention to veterans, but was (4) unrelated to the domains of
function theorized to be important for PTSD.

Statistical Analyses
Statistical analyses were completed in R Statistical Software
Package (http://cran.r-project.org). Separate logistic regressions
were used to examine baseline predictors of training completion
and included (a) clinical measures (CAPS, BDI-II, NSI, and SSS;
all variance inflation factors (VIFs) <2.0), (b) age, education, and neuropsychological function (all VIFs <1.2), (c) ROI PSC during the MSIT, and (d) ROI PSC during the emotional anticipation task. Bonferroni correction resulted in a critical p ≤ 0.012. To assess the unique variance of each variable within the models, a p-value of 0.050 was used.

Separate linear mixed models were used to assess changes
in each of the nine Lumosity training task brain processing
index (BPI; a proprietary algorithm created by Lumosity
to index task performance). Time was entered as both a
fixed and random effect, and participant as a random effect.
Bonferroni correction resulted in corrected critical p-values
of 0.006.

To assess the potential benefits of training on measures
of clinical symptoms, neuropsychological function, and brain
function, we calculated z-scores for each subject that competed
either EFT or placebo training (relative to the control group)
for pre- and post-treatment. A z-score allowed for comparisons
across measures, as well as the ability to compare individual
changes in each domain (>1 z-score interpreted as potentially
clinically significant). To inform power analyses for future
studies, we report t-tests exploring time effects (combining EFT
and placebo groups).

RESULTS

Feasibility of Training
Dropout rates for EFT (n = 14) and placebo (n = 6) training were
42.8 and 50.0%, respectively. Within the EFT group, six veterans
withdrew from the study (Table 2). One veteran withdrew prior
to receiving training instructions, another veteran moved out of
the state; the remaining four were unable to be reached for follow-
up. Within the placebo group, three participants withdrew. One
veteran indicated a lack of time and another indicated lack of
motivation, frustration with the games, and “personal issues.”
One veteran was unable to be reached for follow-up. On average,
veterans completed 6.15 weeks of training, and completed an
average of 535 individual games, equating to ∼858 training
minutes (Table 2).

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Clausen et al. Executive Function Training and PTSD

TABLE 2 | Executive functioning training summary.

Participant Completed? Number of games

completed (% of required

training completed)

Weeks

completed (#)

1 Yes 548 (97.9%) 6

2 No 56 (10%) 3

3 Yes 560 (100%) 6

4 Yes 512 (91.4%) 8

5 Yes 560 (100%) 6

8 Yes 560 (100%) 6

9 No 22 (3.9%) 1

10 Yes 563 (100%) 6

11 No 0 (0.0%) 0

12 Yes 531(94.8%) 6

13 Yes 563 (100%) 7

14 No 0 (0.0%) 0

15 Yes 414 (73.9%) 8

16 No 0 (0.0%) 0

Accessibility and Acceptance of Treatment
Eight veterans completed the EFT post-intervention
questionnaire. Seven veterans agreed or strongly agreed the
number of sessions, and duration of sessions were appropriate.
All agreed or strongly agreed (a) with the delivery method of
the intervention (computer-based training completed at home),
(b) that the instructions were easy to comprehend, and (c) that
the intervention was easy to access. Five veterans indicated
preference for completing computer-based training at home,
while three indicated no preference.

Six veterans agreed or strongly agreed that EFT beneficially
impacted PTSD symptoms. All veterans felt EFT beneficially
impacted their cognitive functioning. Seven veterans agreed or
strongly agreed that EFT was fun and interesting. One veteran
strongly agreed the intervention was boring and tiresome.
When asked hypothetically if EFT was found to be effective
for PTSD and offered as a treatment, one veteran indicated
they would engage in the current treatment offered alone,
while seven indicated they would engage in EFT combined
with psychotherapy.

Predictors of Treatment Completion
Logistic regression indicated, when compared to the null model,
the clinical predictors included in the model (PTSD, depressive,
neurobehavioral and sensation seeking symptoms) yielded a
better fit (AUROC = 0.94, LRT = −14.42, x2 = 18.47, p < 0.001; Figure 2A) where higher scores were positively associated with higher dropout rates. None of the clinical assessments were uniquely predictive of treatment completion. Cognitive variables were not predictive of treatment completion (AUROC = 0.67, LRT = −14.42, x2 = 2.64, p = 0.267).

PSC within ROI’s during the anticipation task also
significantly predicted treatment completion (AUROC = 1,
LRT = −13.76, x2 = 27.53, p = 0.001; Figure 2B). Decreased
activation within bilateral amygdala and bilateral dorsal

middle frontal cortex, and increased activation within
the dorsal, rostral and ventral ACC, and bilateral insula
were associated with a higher probability of completion.
None of the ROI’s were uniquely predictive of treatment
completion. PSC within ROIs during the MSIT did not predict
treatment completion (AUROC = 0.88, LRT = −13.14,
x2 = 10.08, p = 0.344).

Pre- to Post-treatment Assessment
Veterans showed significant improvement in BPI across training
tasks from pre- to post-EFT treatment (Figure 3; p < 0.001 for each task). Task results are presented in Figure 3 and Supplementary Material. On average, across both treatment groups, PTSD symptoms, measured via the PCL, improved by z = 1.28 with 7 out of 11 veterans demonstrating >1 z-
score improvement from pre- to post-treatment. For depressive
symptoms, an average improvement of z = 0.59 was observed,
with only 3 out of 11 veterans demonstrating >1 z-score
improvement from pre- to post-treatment. Veterans improved
by z = 0.45 on neurobehavioral symptoms with 5 out of
11 veterans demonstrating >1 z-score improvement (Table 3).
Changes in PSC within ROIs during the anticipation task and
the MSIT are presented in Supplementary Materials (Table S1).
However, no specific patterns of change emerged from pre- to
post-treatment.

Specific to psychological symptomology, veterans showed
a significant reduction from pre- to post-treatment in PTSD
[t(10) = 3.12, p = 0.011] and depressive [t(10) = 2.71, p = 0.022]
symptoms. Based on visual inspection and exploratory t-tests,
changes in PTSD and depression symptoms did not appear to
differ substantially based on treatment group (all p’s > 0.100).
However, this analysis was notably limited due to the small
sample sizes. There were no significance differences between pre-
and post-treatment on measures of neurobehavioral symptoms,
impulsivity, executive function, overall neuropsychological
function, or PSC in any ROI (all p’s > 0.100).

DISCUSSION

The present pilot study examined the feasibility and acceptability
of computer-based EFT for combat veterans with PTSD.
Results provide several considerations that can inform future
research. First, veterans who completed EFT indicated it
was enjoyable and they would consider it as an adjunctive
treatment for PTSD if offered. Second, EFT dropout rates were
similar to traditional PTSD interventions (9). Third, clinical
symptomology and brain activation during the anticipation task
were predictive of treatment completion. Last, veterans who
completed either EFT or placebo training showed improvements
in clinical symptomology.

Treatment Compliance
Prior studies assessing compliance for evidence-based
psychotherapy PTSD treatments suggest ∼39% dropout
(42). However, the hope has been that non-trauma focused,
computerized, at home treatments may lead to higher compliance
(19). In support of this, studies examining cognitive training in

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Clausen et al. Executive Function Training and PTSD

FIGURE 2 | (A) clinical predictors of treatment completion including PTSD severity using the PTSD Symptom Checklist (PCL), and the Clinician Administered PTSD

Scale (CAPS), depression severity assessed via the Beck Depression Inventory (BDI)—II, the Neurobehavioral Symptom Inventory (NSI) to assess sequelae of

traumatic brain injury, and the Sensation Seeking Scale (SSS) to assess impulsivity. Completers exhibited less severe symptoms compared to non-completers.

(B) fMRI predictors of treatment completion during an anticipation task (negative–positive affective trials). Regions of interest include bilateral amygdala, insula and

dorsal midfrontal cortex, as well as dorsal, ventral, and rostral anterior cingulate cortex (ACC). Completers displayed hypoactivation within bilateral amygdala, and

dorsal midfrontal cortex and hyperactivity within the rostral and dorsal ACC and left insula relative to non-completers.

depression and TBI report relatively low dropout rates of 0–31%
(17–19). The current study is the first to explore computer-based
training in combat veterans with PTSD. We found a 42.8%
dropout rate for EFT suggesting a similar dropout rate to
traditional PTSD treatments. Future research is warranted to
explore modifiable factors that may influence EFT compliance in

PTSD populations, such as having a designated time and place
to engage in EFT, the dosing of training (frequency or duration
of sessions), or treatments aimed at enhancing motivation (i.e.,
motivational interviewing, psychoeducation).

Prior research examining symptom severity as a predictor
of completion for evidence-based PTSD psychotherapy has

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FIGURE 3 | Training performance throughout the six-week executive function training. Training included the following LumosityTM tasks: Color Match and Lost in

Migration, Brain Shift, Brain Shift Overdrive, Speed Match, Memory Match, Memory Match Overload, Penguin Pursuit, and Disillusion. Overall, veterans showed

improvement across all training tasks.

TABLE 3 | Changes in psychological and neuropsychological scores from pre- to post-treatment.

Participant CAPS PCL BDI-II SSS NSI Executive function NP function

Placebo group (average) −1.26 −0.34 −1.07 −0.73 −0.04 0.22 0.06

4 −0.69 0.14 −0.8 −1.19 0.54 1.03 0.36

6 −2.75 0.14 −0.64 −2.18 −1.34 −0.48 −0.24

7 −0.34 −1.31 −1.76 1.19 0.67 0.1 0.06

EFT group (average) −0.06 −1.25 −0.42 0.23 −0.6 −0.42 0.3

1 0.57 −1.16 −0.32 0.59 1.07 −1.29 −0.21

3 0.46 −2.33 −0.32 0.79 −0.94 0.76 0.75

5 0 −1.89 −0.16 0.99 −1.07 0.03 −0.12

8 −0.12 −1.31 −1.6 −0.4 −1.07 −0.69 0.48

10 0.11 −0.44 0 −1.58 −0.94 −1.05 −0.78

12 −5.73 −4.37 −1.44 NA −2.54 −1.43 0.38

13 1.95 −1.89 0.48 −0.59 −0.54 −1.07 0.61

15 2.29 0.29 0 1.78 1.2 1.38 1.29

EFT, executive function training; CAPS, clinician administered PTSD scale; PCL, PTSD symptom checklist-IV-military version; BDI-II, beck depression inventory II; SSS, sensation seeking

scale; NSI, neurobehavioral symptom inventory; NP, neuropsychological. Negative values indicate a decrease in symptom severity from pre- to post-treatment.

been mixed (42–44). Our results indicate that veterans with
more severe symptoms are less likely to complete computerized
training. The present sample included a relatively wide variability
of symptom severity in a community-based veteran sample, and
assessment encompassed a range of psychological symptoms—
which may have enhanced our ability to detect this relationship.
Given that none of the predictors contributed a unique amount
of variance, findings suggest psychological severity across
symptoms (e.g., PTSD, neurobehavioral) may be predictive of
treatment completion.

Higher pre-treatment dorsal ACC, insula and amygdala
activation during emotional anticipation has been reported to
relate to PTSD treatment completion (45, 46). Our results
highlight similar regions though differed in directionality.
Specifically, results suggest that a balance toward recruitment
of medial PFC regions involved in response inhibition or
more implicit regulation, rather than the amygdala (affective or
salience processing) or lateral PFC regions (executive functions,
and explicit emotion regulation), may support the ability to stay
committed to completing computerized cognitive interventions

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Clausen et al. Executive Function Training and PTSD

[for review of the function of these regions in PTSD see
(47)]. Notably, average correlations between ROI activations
and clinical measures were r = 0.24, suggesting activation
patterns were not simply reflecting symptom severity. It would
be beneficial if future research corroborated unique predictors
for completion of computerized cognitive training vs. trauma-
focused therapy, as this could point toward a personalized
medicine approach.

Acceptance and Impact of EFT
Overall, veterans who completed EFT felt the training modality
was easily accessible, enjoyable, and liked that training was
completed at home. Veterans subjectively reported that EFT
beneficially impacted PTSD symptoms and cognitive abilities.
While all veterans reported a desire to engage in EFT if
offered in a clinical setting, most indicated a preference for
EFT in conjunction with psychotherapy. Given these results
and concerns about generalization of cognitive training effects,
it may be beneficial to conduct EFT in conjunction with
therapy discussions (i.e., concerning relevance of training for
daily functioning or PTSD symptoms). Anecdotally, veterans
demonstrated variability in their reflections about the impact of
completing EFT. One veteran in particular noted connections
between learning to slow down and inhibit automatic responses
on the training tasks with learning to do the same in his daily life
(e.g., stopping himself from yelling at a loved one and instead,
responding in a more adaptive way). However, others would
indicate how they liked the training but did not understand how
it was related to their PTSD symptoms. Implementing cognitive
training within a therapeutic context could potentially enhance
the impact by making these connections between training tasks
and every day functioning.

Veterans in both groups showed PTSD and depressive
symptom reductions from pre- to post-treatment and the
EFT group showed significant improvement on Lumosity
trainings tasks. However, obvious benefits were not observed
in neuropsychological function, self-reported neurobehavioral
symptoms, or brain activation within this small sample. Thus,
it is possible that PTSD and depressive symptom improvement
may be reflective of a placebo effect, or indicate that focused
cognitive exercises, regardless of content, are beneficial. Future
research is needed, with sufficient sample sizes, to further
assess changes in psychological symptoms, cognitive function
and brain activation following EFT compared to an active-
placebo control.

Limitations
Given the focus on male combat veterans, the current study
cannot address acceptability and feasibility of EFT with other
PTSD populations (females; non-combat types of trauma).
The present study focused on a six-week home-based training
protocol, similar to protocols in other populations. While more
obvious clinical benefits may have emerged with a longer
training protocol, there is no data to suggest the optimal
dose for computer-based EFT. Additionally, while home-based
treatments may increase accessibility to treatment, it may
introduce additional limitations to treatment effects, such as

less structured behavioral activation of coming to a clinic, or
increased distractibility while at home. Due to the small sample,
the current study is unable to assess efficacy of EFT compared
to placebo training. Thus, the current results focus on feasibility
and factors related to treatment completion. However, results
from this study can be used to inform future studies examining
the effects of EFT. Specifically, further research with larger
samples is needed to identify whether computer-based EFT
may have significant clinical benefit and if so, the optimal dose
(i.e., number and duration of training sessions) and necessary
components (i.e., working memory, attentional switching, etc.)
of training.

Conclusions
Despite limitations, our results provide an initial framework
to explore the impact of EFT on psychological symptoms,
neuropsychological function and brain activation. Results
suggest that home-based, computerized EFT may have
similar issues with compliance as other evidence-based
PTSD treatments. Lower symptom severity and a balance
toward medial PFC cognitive control regions rather than
affective processing regions or lateral PFC regions during
emotional anticipation may support the ability to complete
such self-driven interventions. Veterans who completed training
reported a high level of acceptance for EFT and suggested
they would choose to complete such training in conjunction
with other treatments. Initial findings suggest that EFT may
relate to subjective and clinically significant improvement
in PTSD and depressive symptoms, but the active treatment
mechanism remains unclear. Future research is warranted
to examine whether computerized EFT may be useful for
augmenting current, evidence-based PTSD treatments and
identifying strategies for improving compliance and efficacy of
such interventions.

DATA AVAILABILITY

The de-identified datasets for this study are available
upon request.

AUTHOR CONTRIBUTIONS

JB, LM, JM, and RA contributed conception and design of the
study. AC, JT, AF, and RA contributed to the acquisition of
data. AC and RA performed the statistical analysis. AC wrote
the first draft of the manuscript. RA and JT wrote sections of the
manuscript. All authors contributed to manuscript revision, read,
and approved the submitted version.

FUNDING

This research was supported by the University of Missouri
Research Board, and The Heartland Institute for Clinical and
Translational Research #UL1TR000001 (RA).

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Clausen et al. Executive Function Training and PTSD

ACKNOWLEDGMENTS

Hoglund Brain Imaging Center is supported by a generous
gift from Forrest and Sally Hoglund and funding from the
National Institutes of Health (S10 RR29577, UL1 TR000001,
and P30 AG035982). Writing of this manuscript was partially
supported by the Department of Veterans Affairs Office
of Academic Affiliations Advanced Fellowship Program
in Mental Illness Research and Treatment, the Medical
Research Service of the Durham VA Health Care System,
and the Department of Veterans Affairs Mid-Atlantic
Mental Illness Research, Education, and Clinical Center

(MIRECC). This study has been listed on clinicaltrials.gov
(NCT01644851). The views expressed in this article are those
of the authors and do not necessarily reflect the position
or policy of the Department of Veterans Affairs or the
United States Government.

SUPPLEMENTARY MATERIAL

The Supplementary Material for this article can be found
online at: https://www.frontiersin.org/articles/10.3389/fpsyt.
2019.00062/full#supplementary-material

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527-01

Conflict of Interest Statement: LM reported receiving funding from the

American Cancer Society (Principal Investigator), the University of Kansas

Research Investment Council (Co-Investigator), the University of Kansas Cancer

Center Pilot Program (Co-Investigator), and the National Institutes of Health

(R01 HD086001 [Co-Investigator]; K23 GM123320 [Collaborator]). RA reported

serving as consultant for a Department of Defense Congressionally Directed

Medical Research Program project (PT100018) and has received funding from

the National Institute of Health (K23MH108707). JB reported that he is a paid

consultant to the National Hockey League and provides unbranded talks for

Novartis. JM, AC, AF, and JT reported no commercial or financial relationships

that could be construed as a potential conflict of interest.

Copyright © 2019 Clausen, Thelen, Francisco, Bruce, Martin, McDowd and

Aupperle. This is an open-access article distributed under the terms of the Creative

Commons Attribution License (CC BY). The use, distribution or reproduction in

other forums is permitted, provided the original author(s) and the copyright owner(s)

are credited and that the original publication in this journal is cited, in accordance

with accepted academic practice. No use, distribution or reproduction is permitted

which does not comply with these terms.

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https://doi.org/10.1038/npp.2011.32

https://doi.org/10.1038/nn1165

https://doi.org/10.1016/j.tics.2010.05.002

https://doi.org/10.1371/journal.pone.0134467

https://doi.org/10.1037/tra0000065

https://doi.org/10.1016/S0005-7967(01)00024-9

https://doi.org/10.1037/a0022705

https://doi.org/10.1016/j.pscychresns.2013.05.001

https://doi.org/10.1038/npp.2015.257

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• Computer-Based Executive Function Training for Combat Veterans With PTSD: A Pilot Clinical Trial Assessing Feasibility and Predictors of Dropout

Introduction
Methods
Participants
Psychological Assessment
Neuropsychological Assessment
fMRI Procedures
Computer-Based Interventions
Executive Function Training
Placebo Word-Game Training
Statistical Analyses
Results
Feasibility of Training
Accessibility and Acceptance of Treatment
Predictors of Treatment Completion
Pre- to Post-treatment Assessment
Discussion
Treatment Compliance
Acceptance and Impact of EFT
Limitations
Conclusions
Data Availability
Author Contributions
Funding
Acknowledgments
Supplementary Material
References

Nature-based therapy as a treatment for
veterans with PTSD: what do we know?

Dorthe Varning Poulsen

Abstract

Purpose – The purpose of this paper is to provide a comprehensive argument for nature-based therapy (NBT)
for veterans with post-traumatic stress syndrome. It is the aim to generate an overview of the evidence for

NBT

to the target group. A review of available scientific literature within the field, has been comprehensively
conducted. This work is the foundation for the recommendations to decision makers and politicians.
Design/methodology/approach – This paper provides a conceptual analyses and a general review of the
literature. Following steps have been conducted. Based on the research question, relevant work (scientific
papers) have been identified using search terms in English within the three areas the target group (veterans),
the diagnosis (post-traumatic stress disorder, PTSD) and treatment (NBT). Study-quality and evidence level
have been assessed and discussed.
Findings – The findings show a wide variation according to the interventions the nature setting, the length and
frequency of the NBT session as well as the health outcome measures. The studies demonstrated a positive
impact on the PTSD symptoms, quality of life and hope. None of the studies found negative impact of the
interventions. Being in a group of other veterans facing the same problems was highlighted as well. Some studies
measured the ability to return to workforce for the veterans and found NBT beneficial in that process.
Research limitations/implications – The limitation of the research due to the methods of identifying
studies. The purpose of this was to give an overview of existing literature, and there can be studies, that are
not found in this process. Including qualitative and quantitative methods are useful in a process of
understanding the impact of NBT for veterans with PTSD. The quantitative studies, which unfortunately are
few, can give information of the extent to which the treatment affects the symptoms of PTSD. Seen in the
perspective of the burden for the veterans suffering from PTSD and the economic burden for society, the
process of synthesizing the research in the field in order to generate a fundament seems necessary.
Practical implications – This policy papers are useful in order to make recommendations for politicians and
decision makers as well as practitioners.
Social implications – The burden of suffering from PTSD is heavy for the veterans and their family.
The society must drive forward the development of new and better evidence-based treatment programs for
veterans with PTSD. NBT might be a step in the right direction of this.
Originality/value – It is well-known that there are an increase in the number of veterans diagnosed with PTSD.
Generally the drop-out rate of the veterans is high in conventional treatment and it is found that veterans
experience some side effects from medical treatment. NBT is, in existing research, found to have a positive
impact on the veterans, and therefore, it should be part of future treatment programs for veterans with PTSD.

Keywords PTSD, Recommendations, Veterans, Nature-based therapy, Post-traumatic stress syndrome

Paper type General review

Introduction

This paper describes society’s obligation to provide appropriate treatment to military personnel
who are suffering from post-traumatic stress disorder (PTSD) following war service. Furthermore,
the paper reviews nature-based therapy (NBT) as a relevant component of an overall treatment.

PTSD can occur after experiencing or witnessing traumatic events (American Psychiatric
Association, 2013). Combat-related PTSD is a condition that has huge personal implications for
the individual and his family, and poses an economic burden for society. The prevalence of PTSD
among the US troops returning from Afghanistan and Iraq has been reported at 14-15 per cent
(Gates et al., 2012), and for UK troops the number is 3-5 per cent (Fear et al., 2010; Richardson

Received 29 August 2016
Revised 17 October 2016
Accepted 17 October 2016

Dorthe Varning Poulsen is an
Assistant Professor at the
Department of Geosciences
and Natural Resource
Management, University of
Copenhagen, Frederiksberg,
Denmark.

DOI 10.1108/JPMH-08-2016-0039 VOL. 16 NO. 1 2017, pp. 15-20, © Emerald Publishing Limited, ISSN 1746-5729 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 15

et al., 2010). Furthermore, the number of soldiers with symptoms compatible with PTSD in the
USA and the UK has increased (Atkinson et al., 2009; Tanielian and Jaycox, 2008). An important
part of this story is that veterans are diagnosed several years after having experienced the
traumatic events and not, as previously, within six months after the onset of symptoms. A Danish
cohort study of veterans from the war in Afghanistan found an increase in the percentage of
soldiers with PTSD symptoms; the figure increased from 3 per cent at the time of homecoming to
9.4 per cent three years after the time of homecoming (Andersen et al., 2013).

The treatment offered to war veterans often consists of either psychological treatment or
pharmacotherapy, or a mix of these two treatment forms. Exposure therapy and cognitive
therapy are recommended in clinical treatment guidelines in several countries (Forbes et al., 2010;
Castillo et al., 2014; Resick et al., 2015). In spite of these recommendations, a percentage of the
veterans deselect the treatment offered; Hoge found that up to 44 per cent of veterans in the USA
do not receive the recommended treatment or drop out of their treatment programme (Hoge
et al., 2014). Therefore, it seems urgent to seek out alternative treatments that work, are
acceptable to war veterans with PTSD, and that have a positive impact on the individual’s overall
life. In this regard, NBT is a promising option.

The aim of this paper is to summarize the existing evidence of the benefits of NBT for veterans
with PTSD, to identify strengths and weaknesses in the research conducted, and, based on this,
to make recommendations with regard to how to incorporate NBT as a part of the treatment
offered to war veterans with PTSD.

NBT

NBT covers a variety of interventions in which the nature setting (designed or natural) and the
therapeutic programs constitute a relationship that is adjusted to the need of the target group
(Stigsdotter et al., 2011). The treatment is based on the theory that environmental psychology
and natural environments are seen as supportive for human health (Stigsdotter and Grahn, 2003;
Stigsdotter et al., 2011). Moreover, it draws on Kaplan’s (1995) theory suggesting that nature can
help to replenish our mental and attentional capacity. Fatigue of the brain can occur when the
brain’s capacity to focus on a specific task has reached its limit. Though the interaction between
the ambient environment, i.e. green activities that have a therapeutic effect, and knowledge of the
special needs of the target group, NBT offers a very real and relevant form of treatment.

In NBT, the therapeutic approach varies from, e.g. mindfulness-based methods, cognitive
therapy or, the development of special skills in relation to nature and horticulture. Even though the
overall goal is to enhance the veterans’ self-confidence and ability to deal with everyday life
situation, the therapeutic aspect is an inseparable part of NBT. Thus it is very important to
differentiate between NBT and outdoor activities. Outdoor activities have a purpose in themselves
and are not directly related to healing; they might have a positive impact on the participants’
mental and physical being in the moment, but they are not designed to lead to the individual’s
recovery. And therefore they should not be included in the assessment of a treatment for veterans
with PTSD.

Below is an overview of existing research within the area of NBT for war veterans with PTSD.
Based on this overview, important matters as well as issues that need further research will be
identified with a view to preparing an evidence-based guideline for NBT for veterans that will
benefit both the veterans and society.

Overview of the existing research

The purpose of this literature review is to give an overview of research concerning NBT for
veterans with PTSD. This review uses the term “NBT” defined by Corazon et al. (2010) as “a
therapeutic intervention targeting the need of a special population, where the natural environment
is specially designed or specially chosen for the particular therapeutic activity”. NBT can be seen
as an umbrella-term for different types of therapy also referred to as ecotherapy, horticultal
therapy and therapeutic horticulture.

PAGE 16 j JOURNAL OF PUBLIC MENTAL HEALTH j VOL. 16 NO. 1 2017

A search strategy was developed inspired from The Cochrane Centre; The Cochrane Handbook
for Systematic Reviews of Interventions (Higgins and Green, 2008).

Search terms within the field of the three foci (“Therapy”, “Target group” and “Diagnose”) were
developed (Table I).

Looking at the field as a whole, there is a huge contrast between the commonness of treatment
programmes for veterans with PTSD involving “nature” (a Google search generated more than
800,000 hits) and the lack of scientific studies of NBT programmes.

A broad search of papers published from 1995-2016 based on English search terms within the field of
“NBT”, “veterans” and “PTSD” was conducted. Two reviews including, respectively, 19 (Poulsen
et al., 2015) and eight studies (Bird, 2014) was found. Additionally, six studies were identified. The
quality of the studies was assessed using recommendations from Cochrane Handbook (Higgins and
Green, 2008). RCT studies are recommended in reviews of medical intervention, because they test
the effectiveness of various types of medical intervention (Higgins and Green, 2008; Popay et al.,
1998). In spite of this, only few RCT studies have examined NBT for veterans with PTSD. A systematic
review (Poulsen et al., 2015) included only two RCT studies published in the period from 1996 to
2015. The same picture was seen in a review focussing on treatment of Australian veterans in which
the author concluded that research in this area is based mainly on “small self-selected sample sizes
and a lack of randomised controlled groups” (Bird, 2014). The two reviews found a greater number of
qualitative designed studies: (Poulsen and Stigsdotter, 2015) included 17 of such studies and Bird
included eight papers in his review. Qualitative studies are often used in social research because of
their value with regard to investigating complex and sensitive issues (Bryman, 2015), but as described
above, they are not usually part of reviews of medical interventions. The consequences of not
including this type of research in this particular field might be that rigorous data that are relevant to
policy are not included in review studies. A transparent assessment of the methodology’s quality
before analyzing the data, as done by Poulsen (Poulsen and Stigsdotter, 2015) is required. So what
may be seen as a weakness from a medical methodological perspective can instead be viewed as a
quality in research within the social research, and bring deeper insight into the participants’ experience
of the treatment and life perspective. This paper argues for a biopsychosocial approach (Borrell-Carrio
et al., 2004; Engel, 1989) and therefore, the qualitative as well as the quantitative studies are reviewed.

Results

In general, the interventions varied especially with regard to the setting, the length and frequency
of intervention and also the health outcome measures. A measurement in the studies is the
individual’s ability to return to the workforce. This is an interesting measurement, because of
the high rate of unemployment among veterans (Resnick and Rosenheck, 2008; Smith et al.,
2005) and the resulting economic consequences for the individual and society. Concrete skills
such as horticulture and gardening give the veterans competences that are described as
transferable from the context of the garden to the personal life of the veterans (Poulsen and
Stigsdotter, 2015). In spite of the differences between the studies, there is a tendency that an
extended treatment period of one month instead of shorter compressed intervention periods
(days or a week) has an impact in the long term (Poulsen et al., 2015). Some studies describe
improved physical health as a consequence of the physical demands of green activities. Physical
health is an important measure because of the known negative impact of PTSD on general health.
Most of the researched papers mentioned the veterans’ experience of being part of a group with

Table I The table gives an overview of the search strategy

Search topic Therapy Target group Diagnose

Search terms
(only in English)

Nature-based therapy,
ecotherapy, horticultural
therapy

Veterans, soldiers, military
personnel, servicemen

Post-traumatic stress disorder
(PTSD), combat disorder,
war-related trauma

Databases Medline, Pubmed, Cochrane Library, CINAHL, PILOTS, Google Scholar

VOL. 16 NO. 1 2017 j JOURNAL OF PUBLIC MENTAL HEALTH j PAGE 17

other veterans who face the same type of problems. This feeling of belonging to a group breaks
down the feeling of being stigmatized and isolated (e.g. Atkinson, 2009; Detweiler et al., 2010).
Two studies found a significant reduction in PTSD symptoms and depression, an improvement in
functioning, in hope, and sense of control of the symptoms of PTSD (Duvall and Kaplan, 2013;
Gelkopf et al., 2013; Hyer et al., 1996), whereas Hyer et al. (1996) only found this in the qualitative
part of their study. A recent study (Detweiler et al., 2015) that used cortisol levels and questionnaires
as a measurement of the severity of PTSD in veterans, found no significant difference in the cortisol
levels for the two treatment groups (one group was treated with horticultural therapy (HT) and the
other group was treated with occupational therapy (OT). However, the qualitative part of the study
did show that the majority of participants benefitted more from HT than OH. Only one study
followed the participants after the intervention (Poulsen et al., 2015). This qualitative study examined
a ten-week NBT programme; after one year the veterans were found to have benefited from the
therapy in that their PTSD symptoms were less severe and their sense of control had improved.
Furthermore, the majority of the group had returned to work or education.

Conclusion and recommendations for policy makers

Society is facing an increasing number of war veterans experiencing symptoms of PTSD after
serving in war zones. Added to this, a number of studies indicate there is a connection between
PTSD and an increased rate of physical health issues, substance abuse, and unemployment.
Treatment most often focusses on medical treatment and trauma-focussed psychological
therapy. The literature discusses whether medical treatment can cure PTSD or merely offers
symptom relief. Studies show that many veterans do not seek help or drop out of the
programmers offered. This leaves a group of veterans and their families with the burden of dealing
with the PTSD symptoms in their daily lives.

Even though the majority of the studies have a qualitative approach and only a few RCT studies
have been identified, the results with regard to the effect of NBT are consistently positive and no
negative impact from NBT has been reported.

The qualitative studies of NBT provided to veterans contribute with knowledge regarding the
complex condition of living with PTSD. More well-structured RCT studies are needed in the area.
Such studies, combined with relevant transparent qualitative studies must be the foundation for
developing clear guidelines for NBT. Therefore, the following steps are recommended:

■ Development of a set of measurement tools with a multi-method approach that captures the
different challenges the veterans are facing, and provides a basis for comparing the results of
different projects;

■ Clear and transparent description of the therapeutic approach and interaction with nature
enabling practitioners (therapists) to use this approach, to make the treatment transparent
and transferable to the practice sector; and

■ Clear distinctions between outdoor activities and NBT. Outdoor activities do not involve
a specific therapeutic effort, and are therefore not a treatment even though it appears so
in the literature.

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Corresponding author

Dorthe Varning Poulsen can be contacted at: dvp@ign.ku.dk

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