Treating PTSD in Military Personnel A Clinical Handbook, 2nd

Edition

Visit the link below to download the full version of this book:

https://medidownload.com/product/treating-ptsd-in-military-personnel-a-clinical-
handbook-2nd-edition/

Click Download Now

Treating PTSD
in Military
Personnel
A Clinical Handbook

SECOND EDITION

edited by
Bret A. Moore
Walter E. Penk

Foreword by Matthew J. Friedman

THE GUILFORD PRESS

New York  London
© 2019 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

No part of this book may be reproduced, translated, stored in a retrieval system,

or transmitted, in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
of practice that are accepted at the time of publication. However, in view of the
possibility of human error or changes in behavioral, mental health, or medical
sciences, neither the authors, nor the editors and publisher, nor any other party who
has been involved in the preparation or publication of this work warrants that the
information contained herein is in every respect accurate or complete, and they are
not responsible for any errors or omissions or the results obtained from the use of such
information. Readers are encouraged to confirm the information contained in this
book with other sources.

The views expressed in this book are those of the authors and do not reflect the
official policy or position of the Department of the Army, Department of the
Navy, Department of the Air Force, Department of Defense, or the United States
Government. All case vignettes used in this volume are either fictitious or have been
disguised to protect confidentiality.

Library of Congress Cataloging-in-Publication Data

Names: Moore, Bret A., editor. | Penk, Walter, editor.
Title: Treating PTSD in military personnel : a clinical handbook / edited by Bret A.
Moore, Walter E. Penk ; foreword by Matthew J. Friedman.
Description: Second edition. | New York : The Guilford Press, [2019] | Includes
bibliographical references and index.
Identifiers: LCCN 2018052892 | ISBN 9781462538447 (hardcover : alk. paper)
Subjects: LCSH: Post-traumatic stress disorder—Treatment—United States. |
Soldiers—United States—Psychology. | Veterans—United States—Psychology. |
Soldiers—Mental health—United States. | Veterans—Mental health—United States.
| War neuroses—Prevention.
Classification: LCC RC552.P67 T7655 2019 | DDC 616.85/212—dc23
LC record available at https://lccn.loc.gov/2018052892
To Lori, Kaitlyn, Chester, Duchess, Goldie,
and Fishie
—B. A. M.

To Mark, Janice, Erica, and Danielle

—W. E. P.
 About the Editors

Bret A. Moore, PsyD, ABPP, is a clinical psychologist and prescribing

psychologist in San Antonio, Texas, and the Vice Chair of the Boulder
Crest Institute for Posttraumatic Growth in Bluemont, Virginia. He is the
founder of Military Psychology Consulting and a former active-duty Army
psychologist and two-tour veteran of Iraq. Dr. Moore is author or editor of
numerous books for mental health professionals and general readers. He is
a Fellow of the American Psychological Association (APA) and a recipient
of the Arthur W. Melton Award for Early Career Achievement in Mili-
tary Psychology from APA Division 19 and the Early Career Achievement
Award in Public Service Psychology from APA Division 18.

Walter E. Penk, PhD, ABPP, is Professor of Psychiatry and Behavioral Sci-

ences at Texas A&M College of Medicine and Consultant to Social and
Community Reintegration Research at the Edith Nourse Rogers Memo-
rial Veterans Hospital in Bedford, Massachusetts. He has served at VA
Medical Centers in Houston, Dallas, Boston, and Bedford, and was Direc-
tor of Psychological Services for the Massachusetts Department of Mental
Health. Dr. Penk is a recipient of the Alfred M. Wellner, PhD, Lifetime
Achievement Award from the National Register of Health Service Psychol-
ogists; the Life Achievement Gold Medal for Practice in Psychology and the
Presidential Citation from the APA; the Harold M. Hildreth Distinguished
Public Service Award from APA Division 18; and the Charles S. Gersoni
Military Psychology Award from APA Division 19, among other honors.
He has published more than 160 articles and several books.

vi
 Contributors

Nathan D. Ainspan, PhD, Transition to Veterans Program Office, U.S. Department

of Defense, Alexandria, Virginia
Danielle S. Berke, PhD, Department of Psychology, Hunter College,
The City University of New York, New York, New York
Cara L. Blevins, MA, Health Psychology Program, Department
of Psychological Science, University of North Carolina at Charlotte,
Charlotte, North Carolina
William L. Brim, PhD, Center for Deployment Psychology, Department of Medical
and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Nigel E. Bush, PhD, Psychological Health Center of Excellence,
Defense Health Agency, Tacoma, Washington
Jessica Carney, BA, Massachusetts Veterans Epidemiology Research
and Information Center (MAVERIC), VA Boston Healthcare System,
Boston, Massachusetts
Russell B. Carr, MD, CDR USN, Walter Reed National Military Medical Center
and Uniformed Services University of the Health Sciences, Bethesda, Maryland
Christine A. Courtois, PhD, ABPP, independent practice, Washington, DC (retired),
and Trauma Psychology and Trauma Treatment, Bethany Beach, Delaware
Tessa C. Denman, BA, Warriors Research Institute, Waco, Texas
Vanessa D’Orio, PhD, Psychology Service, VA Boston Healthcare System,
Boston, Massachusetts
Sunny J. Dutra, PhD, Clinical Psychology Department, William James College,
Newton, Massachusetts

vii
viii Contributors

Gary Elkins, PhD, ABPP, Department of Psychology and Neuroscience,

Baylor University, Waco, Texas
Charles R. Figley, PhD, Traumatology Institute, Tulane University,
New Orleans, Louisiana
Edna B. Foa, PhD, Center for the Treatment and Study of Anxiety,
Department of Psychiatry, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania
Julian D. Ford, PhD, ABPP, Center for Trauma Recovery and Juvenile Justice
and Center for the Treatment of Developmental Trauma Disorders,
University of Connecticut Medical Center, Farmington, Connecticut
Tara E. Galovski, PhD, Women’s Health Sciences Division, National Center
for PTSD, and Department of Psychiatry, Boston University School of Medicine
and VA Boston Healthcare System, Boston, Massachusetts
Taryn C. Greene, BA, Health Psychology Program, Department
of Psychological Science, University of North Carolina at Charlotte,
Charlotte, North Carolina
Suzy Bird Gulliver, PhD, Warriors Research Institute, Waco, Texas,
and Texas A&M University Health Science Center, College Station, Texas
Jasmeet P. Hayes, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Nicholas Holder, PhD, Department of Psychiatry, University of Texas
Southwestern Medical Center, Dallas, Texas
Terence M. Keane, PhD, National Center for PTSD, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Nathan A. Kimbrel, PhD, Durham VA Medical Center, VA VISN 6 Mental Illness
Research Education and Clinical Center, and Department of Psychiatry,
Duke University School of Medicine, Durham, North Carolina
Nora Kline, MA, Massachusetts Veterans Epidemiology Research
and Information Center (MAVERIC), VA Boston Healthcare System,
Boston, Massachusetts
Kristen M. Kraemer, PhD, Harvard Medical School and Department
of General Medicine and Primary Care, Beth Israel Deaconess Medical Center,
Boston, Massachusetts
Marc I. Kruse, PhD, Austin Fire Department and Austin–Travis County
Emergency Medical Services, Austin, Texas
Harold S. Kudler, MD, Mental Health Services, Veterans Health Administration,
Washington, DC, and Department of Psychiatry, Duke University School of Medicine,
Durham, North Carolina
Meredith S. H. Landy, PhD, CPsych (supervised practice), Department of Psychology,
Ryerson University, Toronto, Ontario, Canada
 Contributors ix

Howard Lipke, PhD, Department of Psychology, Rosalind Franklin University

of Medicine and Science, Chicago, Illinois
Dolores Little, PhD, U.S. Department of Veterans Affairs, Washington, DC (retired)
Brett T. Litz, PhD, Massachusetts Veterans Epidemiology Research
and Information Center (MAVERIC), VA Boston Healthcare System; College of Arts
and Sciences, Boston University; and Department of Psychiatry, Boston University
School of Medicine, Boston, Massachusetts
Christina M. Luberto, PhD, Harvard Medical School and Department of Psychiatry,
Behavioral Medicine Service, Massachusetts General Hospital, Boston, Massachusetts
David D. Luxton, PhD, MS, University of Washington School of Medicine,
Seattle, Washington
Alexia G. Maness, BS, Warriors Research Institute, Waco, Texas
Susan M. McGlynn, PhD, Psychology Service, VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Donald Meichenbaum, PhD, Department of Psychology, University of Waterloo,
Waterloo, Ontario, Canada, and the Melissa Institute for Violence Prevention
and Treatment, Miami, Florida
Eric C. Meyer, PhD, VA VISN 17 Center of Excellence for Research
on Returning War Veterans, Central Texas Veterans Healthcare System; Department
of Psychiatry and Behavioral Sciences, Texas A&M University Health Science Center;
and Warriors Research Institute, Baylor Scott & White Health, Waco, Texas
Candice M. Monson, PhD, CPsych, Department of Psychology, Ryerson University,
Toronto, Ontario, Canada
Bret A. Moore, PsyD, MSCP, ABPP, Military Psychology Consulting,
San Antonio, Texas
Sandra B. Morissette, PhD, Department of Psychology, University of Texas
at San Antonio, San Antonio, Texas
Emily M. O’Bryan, MA, Department of Psychology, University of Cincinnati,
Cincinnati, Ohio
John D. Otis, PhD, Research Service, VA Boston Healthcare System
,and the Center for Anxiety and Related Disorders, Department of Psychological
and Brain Sciences, Boston University, Boston, Massachusetts
Walter E. Penk, PhD, ABPP, Department of Psychiatry and Behavioral Sciences,
Texas A&M College of Medicine, New Braunfels, Texas
Alan L. Peterson, PhD, Department of Psychiatry, School of Medicine,
University of Texas Health Science Center at San Antonio, San Antonio, Texas
Patricia A. Resick, PhD, ABPP, Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center, Durham, North Carolina
x Contributors

David S. Riggs, PhD, Center for Deployment Psychology, Department of Medical

and Clinical Psychology, Uniformed Services University of the Health Sciences,
Bethesda, Maryland
Lynae Roberts, MA, Department of Psychology and Neuroscience, Baylor University,
Waco, Texas
M. David Rudd, PhD, Department of Psychology, University of Memphis,
Memphis, Tennessee
Mark C. Russell, PhD, School of Applied Psychology, Counseling,
and Family Therapy, Antioch University, Seattle, Washington
William M. Sauvé, MD, Greenbrook TMS NeuroHealth Centers, Richmond,
Virginia, and Neuroscience Education Institute, Carlsbad, California
Richard Sears, PsyD, ABPP, Center for Clinical Mindfulness and Meditation,
University of Cincinnati, and Cincinnati VA Medical Center, Cincinnati, Ohio
Nancy A. Skopp, PhD, Psychological Health Center of Excellence,
Defense Health Agency, Tacoma, Washington
Stephen M. Stahl, MD, PhD, Department of Psychiatry, University of California,
San Diego, La Jolla, California, and Department of Psychiatry, University
of Cambridge, Cambridge, United Kingdom
Samuel Stork, BA, Department of Psychology and Neuroscience, Baylor University,
Waco, Texas
Alina Surís, PhD, ABPP, VA North Texas Health Care System, and Department
of Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas
Richard G. Tedeschi, PhD, Department of Psychological Science,
University of North Carolina at Charlotte, Charlotte, North Carolina
Matthew T. Tull, PhD, Department of Psychology, University of Toledo, Toledo, Ohio
Jennifer J. Vasterling, PhD, Psychology Service and National Center for PTSD,
VA Boston Healthcare System, and Department of Psychiatry, Boston University
School of Medicine, Boston, Massachusetts
Mieke Verfaellie, PhD, Memory Disorders Research Center, VA Boston
Healthcare System, and Department of Psychiatry, Boston University School
of Medicine, Boston, Massachusetts
Anne C. Wagner, PhD, CPsych, Department of Psychology, Ryerson University,
Toronto, Ontario, Canada
Amy M. Williams, PhD, Steven A. Cohen Military Family Clinic at Metrocare
and University of Texas Southwestern Medical Center, Dallas, Texas
Julie D. Yeterian, PhD, Massachusetts Veterans Epidemiology Research
and Information Center (MAVERIC), VA Boston Healthcare System,
and Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
 Foreword

A s research on effective treatments for posttraumatic stress disorder

(PTSD) expands in quantity, quality, and variety, this second edition
of Bret Moore and Walter Penk’s Treating PTSD in Military Personnel
is both timely and welcome. First and foremost, Moore and Penk address
the unique challenges of treating military personnel with PTSD during
an active deployment cycle where mobilization to the war zone from the
home front, and back again, profoundly affect the treatment context. Fur-
thermore, military culture is the elephant in the room that must be clearly
understood and appreciated if the practitioner hopes to communicate accu-
rately, engage meaningfully, and succeed clinically with service members.
As I stated in my Foreword to the first edition of this book, the initial chap-
ter (on military culture) “should be mandatory reading for any nonveteran
civilian [or military] practitioner who hopes to achieve meaningful engage-
ment with previously deployed men and women.” The contextual signifi-
cance of military culture is reiterated throughout each succeeding chapter
so that, for example, a discussion of a particular treatment approach is
presented quite specifically within a pre/postdeployment framework. There
is great overlap, to be sure, between the provision of a cognitive-behavioral
treatment to civilians and to veterans, but this book emphasizes and clari-
fies the uniquely military contextual issues that must be incorporated into
treatment delivery and the therapeutic relationship.
As before, the book is both comprehensive and specific in scope. Each
important PTSD treatment currently in use—prolonged exposure therapy,
cognitive processing therapy, eye movement desensitization and reprocess-
ing, psychodynamic psychotherapy, group therapy, couple/family therapy,

xi
xii Foreword

psychopharmacological treatment, and psychosocial rehabilitation—is

covered in separate chapters. The book is also quite practical in focus, pro-
viding specific assessment tools and treatment approaches, when indicated.
Part II, with its 10 chapters that address the complex clinical presentations
that are the rule, rather than the exception, is a unique contribution of this
book. Moore and Penk have wisely dedicated specific chapters to a number
of co-occurring diagnoses (e.g., affective and anxiety disorders, substance
use disorders, chronic pain, traumatic brain injury, and sleep disorders) as
well as co-occurring clinical problems that are often encountered along
with PTSD, such as suicidal ideation and military sexual trauma. Other
pertinent, complicated, and controversial topics are addressed in the final
chapters, such as moral injury, “complex traumatic disorders,” and post-
traumatic growth. Each chapter is addressed to the clinician in the trenches
and provides a thorough review of whatever literature might be available,
as well as thoughtful practical guidance regarding the best clinical man-
agement of these typically difficult patients. Including a clinical vignette
in each chapter is especially helpful for enabling practitioners to apply the-
ory, research results, and recommendations from the recently revised U.S.
Department of Veterans Affairs/Department of Defense (VA/DoD) Clini-
cal Practice Guideline for the Management of Posttraumatic Stress Disor-
der and Acute Stress Disorder in order to initiate the best treatment for the
service member in their office.
Some chapters focus on new conceptual approaches and empirical
findings that caused the editors to consider treatments that received little
or no attention in the first edition of this volume. Specifically, new chap-
ters in this edition represent important developments and controversies in
the field on mindfulness-based therapies, couple and family intervention,
complementary and alternative therapies, chronic pain and PTSD, treating
moral injury, treating complex traumatic stress disorders, and identifying
and facilitating posttraumatic growth.
The final chapter focuses on posttraumatic growth, which is not the
opposite of PTSD but may develop concurrently with the disorder. Post-
traumatic growth and resilience are both very important emerging areas
that are especially relevant to service members, as well as to the rest of us.
I hope to see much more work in this area by the time Moore and Penk
produce the next edition of this book. Specifically, I hope that research in
these areas will lead to evidence-based resilience techniques that effectively
prevent the onset of PTSD and related disorders. The chapter on stress
inoculation training is a good place to start, but there is much more to do
in this regard.
As most chapters in this volume emphasize, repeatedly, there is always
room for improvement, especially because of the unique challenges associ-
ated with providing effective treatments during an active deployment cycle
when service members are rarely in one place long enough to receive a full
 Foreword xiii

8- to 12-week course of our most effective cognitive-behavioral therapies

(CBTs). Recent research comparing intensive CBT, delivered within a few
days, to evidence-based 8- to 12-session CBT is especially relevant to mili-
tary personnel with limited availability to participate in any CBT protocol.
The possible effectiveness of augmentation with mindfulness or comple-
mentary–alternative or somatic (such as repetitive transcranial magnetic
stimulation [rTMS]) approaches is an important area for future research.
The current search for PTSD phenotypes and genome-based treatments that
will enable us to identify specific subtypes of (this heterogeneous disorder
that we currently call) PTSD will, undoubtedly, improve the effectiveness
of future pharmacotherapy, as we enter the new era of precision medicine.
Moore and Penk have, once again, assembled a distinguished panel of
contributors who have produced a unique book that covers the full range of
effective treatments for PTSD and related disorders without ever losing its
specific focus on military personnel and veterans. It is both a scholarly and
a practical resource for practitioners that is full of sound clinical advice,
a guide to the best assessment instruments and treatment manuals, and
thoughtful clinical vignettes. It remains a very important contribution to
all of us.

M atthew J. F riedman, MD, PhD

National Center for PTSD
U.S. Department of Veterans Affairs
and Geisel School of Medicine at Dartmouth
 Contents

Introduction: PTSD in the Military 1

B ret A. M oore and Walter E. P enk

PART I. Treatment Approaches for PTSD

in Military Personnel

1. Understanding and Working within the Military Culture 9

B ret A. M oore

2. Issues in Assessment of PTSD in Military Personnel 22

S unny J. D utra , J asmeet P. H ayes, and Terence M. K eane

3. Prolonged Exposure Therapy 46

A lan L. P eterson , E dna B. F oa , and D avid S. R iggs

4. Cognitive Processing Therapy 63

A my M. W illiams, Tara E. G alovski , and Patricia A. R esick

5. Eye Movement Desensitization and Reprocessing 78

M ark C. R ussell , H oward L ipke , and C harles R. F igley

6. Mindfulness‑Based Behavioral and Cognitive Therapies 95

E mily M. O’B ryan , K risten M. K raemer , C hristina M. L uberto,
and R ichard S ears

xv
xvi Contents

7. Psychodynamic Psychotherapy 117

H arold S. K udler and R ussell B. C arr

8. Stress Inoculation Training: 136

A Resilience‑Engendering Intervention
D onald M eichenbaum

9. Cognitive‑Behavioral Conjoint Therapy for PTSD: 151

Theory and Practice of Couple and Family Interventions
A nne C. Wagner , M eredith S. H. L andy, and C andice M. M onson

10. Group Therapy for PTSD 169

Walter E. P enk , D olores L ittle , and N athan D. A inspan

11. Psychopharmacological and Neuromodulation Treatment 191

W illiam M. S auvé and S tephen M. S tahl

12. Complementary and Alternative Therapies 214

G ary E lkins, Lynae Roberts, and S amuel S tork

13. Psychosocial Rehabilitation 234

Walter E. P enk , D olores L ittle , and N athan D. A inspan

PART II. Specific Clinical Issues Associated with PTSD

14. Co‑Occurring Affective and Anxiety Disorders 255

E ric C. M eyer , N athan A. K imbrel , M atthew T. Tull ,
and S andra B. M orissette

15. Co‑Occurring Substance Use Disorders 272

M arc I. K ruse , Tessa C. D enman , A lexia G. M aness,
and S uzy B ird G ulliver

16. Chronic Pain and PTSD 296

J ohn D. O tis

17. Traumatic Brain Injury 314

J ennifer J. Vasterling , M ieke V erfaellie , S usan M. M c G lynn ,
and Vanessa D’O rio