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Collection Highlights

Military Past Civilian Present International Perspectives

on Veterans Transition from the Armed Forces Paul Taylor

Equine Assisted Mental Health Interventions Harnessing

Solutions to Common Problems Kay Sudekum Trotter

Understanding Your 7 Emotions CBT for Everyday Emotions

and Common Mental Health Problems 1st Edition Howells

Aging and mental health Qualls

Madness and Genetic Determinism: Is Mental Illness in Our
Genes? Patrick D. Hahn

Reading and Mental Health Josie Billington

Equine Assisted Mental Health Interventions Harnessing

Solutions to Common Problems 1st Edition Kay Sudekum
Trotter And Jennifer N. Baggerly

DDT Wars Rescuing Our National Bird Preventing Cancer and

Creating the Environmental Defense Fund 1st Edition
Charles F. Wurster

Psychoanalysis and Psychiatry Partners and Competitors in

the Mental Health Field Cláudio Laks Eizirik
Bulletproofing the Psyche
 Bulletproofing the Psyche
Preventing Mental Health Problems in Our
Military and Veterans

Kate Hendricks Thomas, PhD, and David L. Albright,

PhD, Editors

Foreword by Charles R. Figley, PhD

Copyright © 2018 by Kate Hendricks Thomas, PhD and David L. Albright,
PhD
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, except for the inclusion
of brief quotations in a review, without prior permission in writing from the
publisher.
This book discusses treatments (including types of medication and mental
health therapies), diagnostic tests for various symptoms and mental health
disorders, and organizations. The authors have made every effort to present
accurate and up-to-date information. However, the information in this book
is not intended to recommend or endorse particular treatments or
organizations, or substitute for the care or medical advice of a qualified
health professional, or used to alter any medical therapy without a medical
doctor’s advice. Specific situations may require specific therapeutic
approaches not included in this book. For those reasons, we recommend that
readers follow the advice of qualified health care professionals directly
involved in their care. Readers who suspect they may have specific medical
problems should consult a physician about any suggestions made in this
book.

Library of Congress Cataloging-in-Publication Data

Names: Thomas, Kate Hendricks, editor of compilation.

Title: Bulletproofing the psyche : preventing mental health problems in our
military and veterans / Kate Hendricks Thomas, PhD, and David L.
Albright, PhD, editors ; foreword by Charles R. Figley, PhD.
Other titles: Preventing mental health problems in our military and veterans
Description: Santa Barbara, California : Praeger, an imprint of ABC-CLIO,
LLC, [2018] | Includes bibliographical references and index.
Identifiers: LCCN 2017048630 (print) | LCCN 2017055776 (ebook) | ISBN
9781440849770 (eBook) | ISBN 9781440849763 (print : alk. paper)
Subjects: LCSH: Veterans—United States—Mental health. | Veterans— United
States—Psychology. | Veterans—United States—Services for. | United States
—Armed Forces—Mental health. | Resilience (Personality trait)— United
States.
Classification: LCC UB357 (ebook) | LCC UB357 .B85 2018 (print) | DDC
616.89/05088355—dc23
LC record available at https://lccn.loc.gov/2017048630
ISBN: 978-1-4408-4976-3 (print)
978-1-4408-4977-0 (ebook)
22 21 20 19 18 1 2 3 4 5
This book is also available as an eBook.
Praeger
An Imprint of ABC-CLIO, LLC
ABC-CLIO, LLC
130 Cremona Drive, P.O. Box 1911
Santa Barbara, California 93116–1911
www.abc-clio.com
This book is printed on acid-free paper
Manufactured in the United States of America
 Contents

Foreword
Charles R. Figley

Acknowledgments and Editors’ Note

Part One Framing the Issues

Chapter 1 Introduction to Military-Connected Well-Being Issues

Jennifer E. C. Lee and Sanela Dursun

Point of View—The Small Bible

Matthew J. M. Hendricks

Chapter 2 Warrior Culture: Ancient Roots, New Meaning

Kyleanne Hunter

Point of View—Armor Down: The Power of Mindfulness

Ben King

Chapter 3 Mindfulness: The Neurobehavioral Basis of Resilience

Deborah Norris and Aurora Hutchinson

Point of View—A Shift on the Mat

Laura Westley

Chapter 4 The Theory and Practice of Training for Resilience

Kate Hendricks Thomas and David L. Albright

Chapter 5 Moral Injury and Resilience in the Military

 Joseph M. Currier, Jacob K. Farnsworth, Kent D. Drescher, and
Wesley H. McCormick

Part Two Current Mental Fitness Programming for Military- and

Veteran-Connected Populations

Chapter 6 Department of Defense Resilience Programming

Cate Florenz and Margaret M. Shields

Point of View—Fostering Veteran-Student Health through

Stress Management: Creating Belonging and Success in a
College Setting through the Veterans at Ease Program
Robin Carnes and Stephen Kaplan

Chapter 7 Mental Fitness and Military Veteran Women

Kelli Godfrey, Justin T. McDaniel, Lydia Davey, Sarah
Plummer Taylor, and Christine Isana Garcia

Point of View—Fitting In and Finding Me

Jessica Wilkes

Chapter 8 Learning from Example: Resilience of Service Members Who

Identify as LGBT
Katharine Bloeser and Heliana Ramirez

Chapter 9 Resilient Military Families

Charles R. McAdams III

Chapter 10 The Promotion of Well-Being in Older Veterans

Kari L. Fletcher, Mariah Rooney O’Brien, and Kamilah A.
Jones

Part Three Collaborating to Provide Mental Fitness Programming for

Military-Connected Populations

Chapter 11 Faith-Based Programming for Spiritual Fitness

 Rev. Sarah A. Shirley, Rev. Elizabeth A. Alders, Howard A.
Crosby Jr., Kathleen G. Charters, and Rev. John Edgar
Caterson

Chapter 12 The Role of Individual Placement and Support (IPS) in Military

Mental Fitness
Lori L. Davis and Richard Toscano

Chapter 13 Adapting the Collective Impact Model to Veteran Services: The

Case of AmericaServes
Nicholas J. Armstrong, Gillian S. Cantor, Bonnie Chapman,
and James D. McDonough Jr.

Point of View—Setting the Bar: Mental Fitness and

Performance
Kate Germano

Chapter 14 The Way Forward

Kelsey L. Larsen and Elizabeth A. Stanley

About the Editors and Contributors

Index
 Foreword

A long time ago, I was a Marine in Vietnam. My war was different from
other conflicts these days (e.g., training, equipment, enemy), but much is the
same. Warfighters have a job to do: to win, to kill, and to complete the
mission. Self-care is not on their to-do list. Not then and not now. But it
should be. We had no idea back then how stress could affect your sleep or
how you can get better sleep by controlling your stress. Common behaviors
such as drinking alcohol or other self-medicating efforts are flawed but
sometimes necessary to restore stasis. Let me return to my experiences later.
This book is about building resilience in military personnel and veterans.
It is an alternative to books that focus on the problems these men and
women face or that emphasize the negative consequences of military service
in the form of mental illness diagnoses. This book is about hope and about
the belief that with effort we are able, all of us, to develop and wear a
bulletproof psyche just as we wear a bulletproof vest into battle. We can
build up our skills, moral compass, integrating honor, mutual support, trust,
and the other tools discussed in this book that better prepare men and
women for severe conditions that persist for prolonged periods of time.
Kate Hendricks Thomas and David L. Albright know about the need for
such skills and resources to enable effective leadership, adaptability, and
creativity to get the job done, no matter what. They were able to recruit not
only the authors who are scholars, researchers, and practitioners to
contribute to this book but also writers who are military veterans, including
combat vets. This mixture of voices leads to a harmony of thoughtful
creativity and reflection about what is needed to effectively serve as a shield
from the horrors of war and its immediate and long-lasting consequences.
Such a shield would enable veterans to go through the phases of reentry to
society and to be effective and loving family members.
The aim of this book is consistent with its theme: embracing and quickly
managing the s*** by taking advantage of the innovations of the
mindfulness movement and other alternative and complementary behavioral
health practices. However, there is a cautionary note at the end of this book.
Despite the best plans and efforts, the military does what it does. New
commanders take over and do the best they can. Sometimes new leadership
ends a successful program, like the ones described in this book.
The characteristics of bulletproofing are largely the same as the concept of
mettle. Mettle is a person’s ability to cope well with difficulties or to face a
demanding situation in a spirited and resilient way. Bulletproofing the
psyche, then, like having the “right stuff,” mettle, or resilience, is about
decreasing the mental health risk factors and increasing the protective
factors. Rather than focusing on a diagnosis (e.g., posttraumatic stress
disorder, depression), the focus is on preventing and bouncing back from
traumatic events.
This book illustrates how and why resilience can be taught and trained. It
is far better than the traditional focus on mental disorders and
psychopathology. The focus is on medical prevention as well as
rehabilitation toward functioning. This is one of the reasons why many are
shifting toward favoring the World Health Organization’s nomenclature over
that of the Diagnostic and Statistical Manual. Focusing on mental illness
diagnoses such as posttraumatic stress disorder is a disservice to those who
are seeking treatment: these types of diagnoses can trigger further problems,
including feelings of shame and of failure, rather than the acknowledgment
that one is injured and requires appropriate rehabilitative care. Self-care and
social support are vital to building resilience.
Indeed, resilience arguments and evidence are becoming popular among
active-duty programs. They are more often focused on preparing warfighters
for the mental and emotional toll that are brought about by combat
operations.
 But no matter their documented success, future military leaders will need
to be educated about their value and kept up-to-date on new findings in this
field. So, despite the extraordinary contributions made in this book, we
cannot count on the lessons being applied in the future. This is in line with
the recent analysis Mark Russell (former Navy Commander and the lead
psychologist treating Marines) and I published through a series of systematic
reviews of military publications and documents (cf., Russell & Figley, 2017a,
2017b, 2017c). We noted that the Department of Defense in general and
frontline psychiatry in particular are failing in their responsibility to prevent
psychiatric casualties and that there are more psychiatric casualties than
physical casualties and wartime psychiatric casualties even exceed combined
totals of personnel physically wounded and personnel killed in action.
When I returned from Vietnam, I had no idea how I had been changed by
my experiences leading Marines and fighting in war. I was fortunate that my
bulletproof vest was for mental bullets, not just metal ones. I was able to
focus my postwar rage generated in Vietnam (1965–1966) on to my academic
studies and degrees. My fortune of a loving family, intellectual and social
resources, and an emerging hate of war motivated me to try to help other
vets find and build their vests. What I have tried to convey is that this book
is about helping war fighters, during and following war, build resilience to
the war stressors.
The military has dual missions of war: fighting wars and force protection.
This requires both protecting those who fight the war and getting them
home in one piece with a plan to promote healing mentally and physically
from their war injuries.
This book provides a way forward to improve military mental health.
Collectively, we can hope that this book will be read by war planners. So far,
the war planners have not worried about a bulletproof “vest” for mental
injury, just vests to prevent physical injury. Protecting our warfighters
during and following battle must be our primary mission on a par with the
military mission. This book is an important start.
Charles R. Figley, PhD
Paul Henry Kuzweg, MD, Distinguished Chair and Professor
 Tulane University
New Orleans, USA

References
Russell, M. C., & Figley, C. R. (2017a). Do the military’s frontline psychiatry/combat and
operational stress control doctrine help or harm veterans? Part one: Framing the issue.
Psychological Injury and Law, 10, 1–23. doi:10.1007/s12207–016–9278-y
Russell, M. C., & Figley, C. R. (2017b). Do the military’s frontline psychiatry/combat
operational stress control programs benefit veterans? Part two: Systematic review of the
evidence. Psychological Injury and Law, 10, 24–71.
Russell, M. C., & Figley, C. R. (2017c). Is the military’s century-old frontline psychiatry
policy harmful to veterans and their families? Part three of a systematic review.
Psychological Injury and Law, 10, 72–95. doi:10.1007/s12 207-016-9280-4
 Acknowledgments and Editors’ Note

We came to this project after many, many conversations about veterans’

well-being issues. Perhaps we work in this space today because our own
experiences leaving the Marine Corps and Army were not ideal—it just
wasn’t as easy to leave and reinvent as we had expected. It is easy to focus
on how things aren’t optimized for military personnel leaving the active
component, but as we chatted, we always turned back to notions of
preventing some of that transition stress. “If I’d only known to do this”
became a familiar refrain. We believe that it doesn’t have to be as hard to
reintegrate into a civilian community for tomorrow’s service members. This
project is the first of our attempts to contribute to and extend the
prevention, rehabilitation, and training conversation for military personnel
navigating that liminal space between service and civilian life and those that
support these processes.
First and foremost, we would like to thank the team of contributors who
lent their expertise, efforts, and skillful prose to this volume. Without you,
there would be no book. The research and personal experiences you shared
are an invaluable gift. We would also like to thank Charlotte Brock, a Marine
Corps veteran and freelance editor, who helped us turn early chapter drafts
into cleaner prose.
Important to mention are our partners, who provide continual support for
our activities, and our children whose enthusiasm and energy sustain us.
Finally, we are forever thankful to the service members, veterans, and their
families and communities.
Many of us return from military service meaningfully changed—
physically, mentally, emotionally, and spiritually. These changes encompass
the whole person and hold the potential to transcend whole communities.
Section one of this anthology will highlight some of these issues and discuss
the physiology of stress injury and other barriers to well-being as well as the
way that hardship can create growth and even “bulletproof the psyche.”
We hope this book contributes to larger community efforts that support
healing. We also hope it motivates a new emphasis on mental fitness
training for the active duty component. Here, rigorous evaluation of existing
outreach efforts provide the foundation upon which savvy programmers
must build. We focus in section two of this book on examining resiliency
programs making inroads with today’s veterans. Our best chance for making
a difference in both the postservice and training environments (before a
service member faces transition stress) involves designing programs from a
baseline of proven success.
To operate in training commands requires great cultural competency,
making mental fitness programming relevant to warfighters working to
maintain readiness and improve performance. The narrative must become
about mission success, not mental health treatment. It means not only trying
to understand the veteran experience but also learning the most effective
ways to communicate with different subsets of the veteran and military
populations. To train is to actively participate, and this is a wellness concept
with which service members are already familiar. Framing self-regulatory
training as a way to “bulletproof the brain” renders palatable a training
opportunity specifically designed to create more effective warriors who
possess mental endurance. Framing mental fitness training as promotion of
combat fitness, resilience, and mental endurance renders it accessible to the
military population. We’re interested in building strengths after all.
We have to speak the language of warriors who have been immersed in
combat operations for over 15 years when we talk about resiliency-
cultivation. PowerPoint presentations simply won’t cut it. By establishing
mental fitness as another component of optimal combat readiness, we
establish such training as a crucial component of mission preparedness and,
as a benefit, remove the stigma of such practices for postdeployment troops
that may be struggling with stress illnesses of varying degrees. The message
can become directive; just as Marines and soldiers learn mission essential
skills and train their bodies for arduous combat, we must adopt practices
designed to train and promote health in the mind, body, and spirit in a
holistic sense. This training doesn’t succeed in sustainable fashion in a
vacuum. Knowing the importance of social support to well-being and
generally wanting to contribute to improved quality of life for service
members require a focus on the larger community in which a warrior
operates. Social and family fitness is part of mental fitness, and we must
consider family readiness programming that is more extensive and
progressive than our current offerings.
When we consider how we could apply these basic recommendations to
military veterans seeking relief from reintegration stress or to active-duty
military preparing for it, we must consider how to make stress management
a testable metric. Biofeedback tools exist that can do this. Checking for
dehydroepiandrosterone and blood cortisol ratios or conducting periodic
blood cortisol checks can be as important as other physical standards are in
the military. Biomarkers tell us quickly whether someone is taking time to
practice balanced wellness.
Section three of this anthology will highlight the possibility of training an
individual to de-escalate his or her nervous system response as a
performance metric and discuss methods for rolling such programs out both
in the active duty component and the veteran space. This anthology’s
primary conclusion is a call to action. We can use biofeedback testing to
make resilience a performance metric for the active duty component. It turns
self-awareness and resilience into standards and motivates learning,
training, practice, and performance in our community’s culture. Our future
work involves delivery and evaluation of a theoretically based, validated
training curriculum to bulletproof the brain.
The future is exciting from clinical, training, and prevention perspectives,
and these recommendations offer tremendous promise for tomorrow’s
military personnel. Training to embrace a mental temerity training regimen
can make them better at their jobs and more resilient in their lives, both
during and after their service to our country.
Kate Hendricks Thomas and David L. Albright
 Part One

Framing the Issues

 Chapter 1

Introduction to Military-Connected
Well-Being Issues
Jennifer E. C. Lee and Sanela Dursun

Together, the wars in Afghanistan and Iraq are among the most hostile
conflicts seen in recent history. Since 2001, over 2.7 million U.S. troops have
been deployed in support of these operations, while over 40,000 Canadian
Armed Forces (CAF) members have been deployed in support of the mission
in Afghanistan (Ramchand, Rudavsky, Grant, Tanielian, & Jaycox, 2015;
Zamorski & Boulos, 2014). There have been more than 8,000 military
casualties among members of the coalition and over 52,000 U.S. military
personnel wounded in action for the conflicts combined (Defence Casualty
Analysis System, 2016). Furthermore, it is widely recognized that the
impacts of war go beyond the immediate fatalities and injuries. Having
faced extreme stress and hostile situations, military personnel are at
increased risk of experiencing mental health problems. These “invisible
wounds” of war have garnered a great deal of attention in recent years
(Tanielian & Jaycox, 2008), with research on the mental health impacts of
recent conflicts in Southwest Asia having surged over the past decade and a
half. A number of well-designed epidemiological studies have now
contributed to a better understanding of the overall burden of
postdeployment mental health outcomes, such as posttraumatic stress
disorder (PTSD) (Averill, Fleming, Holens, & Larsen, 2015). From the
psychological lens, research has also provided substantial insight into the
processes and mechanisms that may explain how exposure to combat stress
gives rise to mental health disorders and, ultimately, influence individuals in
the longer term. Now that an extensive body of work has developed, there is
an opportunity to integrate what is known, identify remaining gaps, and
propose promising strategies to address these. The present chapter provides
an overview of key findings in this area based on research conducted on U.S.
and Canadian military personnel deployed in support of the conflicts in
Southwest Asia since 2001, with the aim of providing a more integrative
perspective of psychosocial pathways in the course of PTSD and its sequelae.

Burden of Postdeployment Mental Health Problems

Given the traumatic nature of combat, it is not surprising that a great deal
of research on the mental health of military personnel has focused on the
psychological impacts of trauma exposure. Despite only having been
formally recognized as a mental health condition in the third American
Psychiatric Association Diagnostic and Statistical Manual (DSM-III) in 1980
(Friedman, 2016), PTSD has evolved into one of the most commonly
researched impacts of combat exposure. As noted by Friedman (2016), the
PTSD concept represented an important shift in psychiatric theory through
the acknowledgment that etiologic factors for the disorder were outside of
the individual rather than resulting from an inherent weakness.
It is argued that the recent missions in Afghanistan and Iraq have created
a unique set of conditions for increased risk of PTSD among military
personnel (Schnurr, Lunney, Bovin, & Marx, 2009): in the United States,
these wars primarily relied on National Guard and reserve forces and
required personnel to go on multiple deployments to meet the demands of
the conflict (Galea et al., 2012); tours were longer, with shorter periods
between them; and, finally, during the tours themselves, commonly reported
stressors included the risk of improvised explosive devices (IEDs), suicide
bombers, or handling human remains among several others (Tanielian,
Jaycox, Adamson, & Metscher, 2008). In turn, significant efforts have been
placed on quantifying the burden of PTSD among military personnel
deployed in support of these missions.
In Canada, an estimated 7.7 percent of Regular Force members with an
Afghanistan-related deployment reported PTSD in the past year according
to a recent survey on mental health in the CAF (Boulos & Zamorski, 2016).
Despite its relatively greater abundance, research on the prevalence of PTSD
among U.S. military personnel returning from deployment to Afghanistan or
Iraq has produced variable results. Indeed, the wide variation in estimates of
PTSD across U.S. studies is among the main criticisms of research in this
area and has been attributed to a number of factors, including differences in
the sampling strategy used across studies, inconsistencies in the timing of
studies relative to deployments, and variations in the case definition used
(Kok, Herrell, Thomas, & Hoge, 2012; Ramchand, Karney, Osilla, Burns, &
Caldarone, 2008; Richardson, Frueh, & Acierno, 2010).
Of note, one important factor that has been found to contribute to the
varying estimated prevalence of PTSD among service members deployed in
support of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
is the specific population under study (Kok et al., 2012). Kok et al. (2012), for
instance, found that the average population-wide prevalence of
postdeployment PTSD was 5 percent, while it was estimated at 13.2 percent
among operational infantry units, which tend to have greater exposure to
ground combat. Some researchers have argued that focusing research on
combat troops is problematic because increased combat exposure in these
groups may result in inflated estimates of PTSD or depression (Hotopf et al.,
2006). Indeed, research that is more generalizable to all deployed personnel is
important to assess the burden of disease and to ensure that mental health
services and resources are correctly allocated (Ramchand et al., 2008). PTSD
is one of many potential postdeployment health outcomes, and it is
important to understand its burden within the context of other problems
that might require an expansion of services and programs. At the same time,
focusing on all deployed personnel without accounting for important
subgroups has some disadvantages, as doing so may obscure important
phenomena contributing to postdeployment PTSD among those at greatest
risk, such as the role of experiential or psychosocial factors that may
exacerbate mental health problems after deployment. To fully understand
the range of factors and phenomena contributing to PTSD among military
personnel, it is also helpful to focus on the specific experiences of those at
greatest risk.

Risk Factors for Postdeployment PTSD

Across studies of military personnel deployed in Southwest Asia, the
finding that has been most consistent is the relationship between combat
exposure and PTSD (Ramchand et al., 2008). Based on a review of medical
records, an estimated 8 percent of CAF members who were deployed in
support of the Afghanistan mission up to 2008 were diagnosed with PTSD
that was attributed to the deployment (Boulos & Zamorski, 2013). In the
United States, an early prospective study that followed a cohort from 2001–
2003 to 2004–2006 found that the incidence of new PTSD was 1.4 percent
among those who were deployed without combat exposure and 7.6 percent
among those who were deployed with combat exposure (according to
specific screening criteria for PTSD). The odds of new-onset PTSD were
between 2.48 and 3.59 percentage points greater among those who were
deployed with combat exposure compared to those who were not deployed,
depending on the branch of service (Smith et al., 2008). While this last
finding demonstrates the persistence of combat exposure as a risk factor for
postdeployment PTSD, it also underlines the variation in risk that may occur
across individuals.
Epidemiological research on the risk factors for postdeployment PTSD has
largely focused on demographic or military characteristics that may
contribute to excess risk. Some of the key individual risk factors for PTSD
identified in a large population-based survey of U.S. military personnel
deployed in support of OEF/OIF included being in the Army or Marine
Corps, in the National Guard or reserve, enlisted, and being female and
Hispanic (Schell & Marshall, 2008). Among CAF personnel deployed in
support of the mission in Afghanistan, risk factors for postdeployment PTSD
have included being unmarried, the experience of stressors on the home
front, and lower rank (Zamorski & Boulos, 2014). For many of these
characteristics, excess risk for PTSD could be explained by differential levels
of combat exposure. Indeed, Army, Marine Corps, and enlisted (or lower
rank) personnel are most likely to be exposed to combat. However, this
explanation is not likely to be sufficient for some of these other risk factors,
particularly the experience of stressors on the home front. Psychological
research has helped shed light on some of these other factors. Of particular
note is the influence of a range of stressors other than those related to
combat on postdeployment mental health outcomes, which may span from
adverse childhood experiences to stressful life events occurring closer to the
time of deployment.
Increasingly, researchers have considered the role of adverse childhood
experiences as factors that may increase vulnerability to postdeployment
PTSD. Early work, for example, revealed that Vietnam veterans with PTSD
reported higher rates of childhood physical abuse than those without PTSD
and that this difference existed even when variation in combat exposure
between the groups was taken into account (Bremner, Southwick, Johnson,
Yehuda, & Charney, 1993). Since then, similar findings have been reported in
other military contexts and in relation to a wider set of mental health
problems (Cabrera, Hoge, Bliese, Castro, & Messer, 2007; Fritch, Mishkind,
Reger, & Gahm, 2010; Iversen et al., 2007). As a potential explanation for
these findings, it has been proposed that exposure to adversity predisposes
individuals to PTSD by increasing their propensity to be exposed to combat
(Iversen et al., 2007). Indeed, exposure to childhood adversity has been
linked with lower educational attainment and lower military rank, which
could result in a greater likelihood of being involved in the front line during
a combat operation (Iversen et al., 2007). A recent longitudinal study of
Canadian military personnel returning from deployment in Afghanistan
found that service members who had reported more adverse childhood
experiences at the time of recruit training reported greater exposure to
combat and that this contributed to lower levels of postdeployment mental
health (Lee, Phinney, Watkins, & Zamorski, 2016). However, these service
members also reported less favorable characteristics on psychological and
social attributes that are believed to confer resilience in the face of adversity,
such as their levels of mastery and social support (Lee, Sudom, & McCreary,
2011), which contributed to lower postdeployment mental health in turn.
Thus, findings provided evidence that were more in line with a stress-
sensitization hypothesis, suggesting that childhood adversity may contribute
to a greater risk of mental health problems by way of their impact on how
individuals interpret or handle stressors (McLaughlin, Conron, Koenen, &
Gilman, 2010).
In addition to adverse childhood experiences, psychological research has
emphasized the importance of considering the full range of stressors that
may be experienced by service members throughout the deployment cycle,
over and above those related to combat. In an investigation of gender
differences in postdeployment mental health problems, it was found that
women reported only slightly less exposure than men to combat-related
stressors. However, they reported greater exposure to other types of
stressors, including predeployment stressors and sexual harassment (Vogt et
al., 2011). Such gender differences were replicated in a more recent analysis,
where it was found that male OEF/OIF veterans reported greater exposure to
mission- related stressors, while female veterans reported greater exposure
to interpersonal stressors (Fox et al., 2016). Differences in these other
stressors also underline the importance of considering factors beyond those
related to combat itself as risk factors for postdeployment PTSD, including
other psychosocial factors. In a prospective longitudinal investigation of U.S.
National Guard soldiers, reporting more stressors prior to deployment,
feeling less prepared for deployment, and reporting more stressful life events
after deployment were associated with greater odds of new-onset probable
PTSD. Conversely, greater social support was associated with lesser odds of
new-onset probable PTSD (Polusny et al., 2011). In a more recent prospective
study of U.S. Marines, the relationship of cohesion among members of the
military unit with various mental health outcomes was examined. Two types
of cohesion were examined: the average level of cohesion across the unit
(unit-level cohesion) and individuals’ perceptions of their cohesion relative
to this average. It was found that unit-level cohesion was not associated
with probable PTSD, but that Marines who perceived higher levels of
cohesion relative to the average level in their unit had lower odds of
probable PTSD (Breslau, Setodji, & Vaughan, 2016). Thus, beyond identifying
risk factors for PTSD among military personnel deployed in support of the
missions in Afghanistan and Iraq, psychological research has helped identify
factors that may be protective.
In addition, psychological research has helped shed light on which specific
aspects of combat are most difficult for individuals. A recent study
examining the relationship between enemy combat tactics being used across
phases of OIF found evidence that asymmetric tactics (i.e., those in which
guerilla-style tactics are used by the enemy rather than conventional
warfare similar to those used by coalition forces) were associated with an
increased risk for PTSD, even after controlling for levels of combat exposure
(Green et al., 2016). Other studies have examined in greater detail which
specific types of combat events were most strongly associated with
postdeployment PTSD. In one study of Canadian military personnel, specific
combat events that were most strongly associated with PTSD were those
that were uncommonly experienced, were unexpected, and could be
interpreted as reflecting some violation of one’s morality (Watkins, Sudom,
& Zamorski, 2016). Born and Zamorski (2017) assessed the fraction of the
burden of PTSD that could be attributed to a range of combat events and
found that, while perceived responsibility for the death of another was
reported infrequently, a substantial proportion of mental health disorder
could be accounted for by exposure to this type of event.
The detrimental effects of certain combat experiences (e.g., the perceived
responsibility for the death of an ally, the inability to respond to threats due
to the rules of engagement, and having witnessed atrocities or massacres) on
mental health have led clinicians and researchers to recognize that the
psychological anguish that many combat veterans experienced was not
represented exclusively by the fear- or terror-based trauma that is the
traditional basis of a PTSD diagnosis (Drescher & Foy, 2008). Rather, beyond
or instead of leading to PTSD, certain experiences may transgress deeply
held moral beliefs and result in less predictable reactions to trauma, such as
guilt and shame, in what has been recently referred to as “moral injury”
(e.g., Litz et al., 2009). Moral injury has been defined as psychological trauma
that can result from “perpetrating, failing to prevent, bearing witness to, or
learning about acts that transgress deeply held moral beliefs and
expectations” (Litz et al., 2009). A consistent theme in moral injury theory
and research is its fundamental connection to feelings of guilt and shame, as
opposed to the fear, helplessness, or horror that are traditionally associated
with PTSD (Dombo, Gray, & Early, 2013; Litz et al., 2009; Steenkamp, Nash,
Lebowitz, & Litz, 2013). The manifestations of moral injury may include an
array of dysfunctional behaviors such as self-harming (e.g., substance
misuse, extreme risk-taking) and self-handicapping (e.g., avoiding positive
experiences and emotions), as well as emotions and cognitions, such as
demoralization (e.g., feelings of confusion, hopelessness, and self-hatred)
(Litz et al., 2009). Bryan, Morrow, Etienne, and Ray-Sannerud (2013),
moreover, found the distress caused by moral transgressions to be
significantly associated with suicidal ideation beyond the effects of
depression and PTSD symptomatology. Thus, the current “standard”
evidence-based PTSD treatment approaches might not be completely
effective in addressing the needs of those who experienced moral injury.

Going beyond Postdeployment PTSD

Emerging research on moral injury has emphasized the importance of
considering a wider range of outcomes in research on the effects of combat
exposure among military personnel. Karney, Ramchand, Osilla, Caldarone,
and Burns (2008) described postdeployment mental health as akin to a ripple
effect, noting that “whereas ripples diminish over time, the consequences of
mental health and cognitive conditions may grow more severe, especially if
left untreated” (p. 149). Thus, equally important is the need to understand
the broader impacts of PTSD on the lives of service members and some of
the factors that may influence its course.
One issue elucidated in research on postdeployment PTSD, and that has
been found to influence clinical outcomes, is its high level of comorbidity
with other mental health disorders. In a survey of OEF/OIF veterans, not
only were PTSD and depression highly correlated, but close to two-thirds of
those with PTSD had probable depression as well (Schell & Marshall, 2008).
Comorbid PTSD and depression are not unique to U.S. OEF/OIF veterans.
One study of Canadian veterans examined the latent profiles of PTSD and
major depression and found three profiles of PTSD and depression
comorbidity. The first was characterized by high levels of symptoms on both
disorders, the second by moderate symptoms on both disorders, and the
third by low symptoms (Armour et al., 2015). Not surprisingly, the group
with high levels of PTSD and depression symptoms reported the least
favorable outcomes in terms of health-related functional impairment. In
another similar analysis, it was found that the dysphoria factor of PTSD in
particular was associated with various depression factors, suggesting that
dysphoric mood underlies PTSD psychopathology (Elhai, Contractor,
Palmieri, Forbes, & Richardson, 2011).
As competing hypotheses for the high prevalence of comorbid PTSD and
depression, it has been proposed that observed comorbidity is the product of
extensive symptom overlap between both disorders; or rather, that this
comorbidity is indicative of the presence of a trauma-related phenotype
(Flory & Yehuda, 2015). Following a review of studies on the etiology of
depression comorbidity in combat-related PTSD, evidence was found
suggesting that PTSD was a risk factor for subsequent depression (Stander,
Thomsen, & Highfill-McRoy, 2014). At the same time, it was recognized that
this association was complex and possibly involved common vulnerabilities
or risk factors and bidirectional relationships (Stander et al., 2014).
Irrespective of the cause, it is widely recognized that comorbid PTSD and
depression are difficult to treat and are associated with poorer outcomes,
including suicide ideation (Flory & Yehuda, 2015). In one study of U.S. Army
personnel, soldiers with both PTSD and depression were found to be almost
three times more likely to report suicide ideation in the past year than those
with only a single disorder (Ramsawh et al., 2014). Furthermore, it was
estimated that, while PTSD and depression each contributed to the overall
risk of suicide ideation in this population, having both disorders
concurrently contributed to the greatest proportion of risk, followed by
having depression alone (Ramsawh et al., 2014).
With PTSD and depression both having been linked with suicide ideation
(LeardMann et al., 2013; Ramchand et al., 2015; Ramsawh et al., 2014), some
studies have focused on clarifying the different pathways that might explain
these associations. In line with findings emphasizing the relationship of
noncombat factors, such as other psychosocial stressors or social resources,
with PTSD among military personnel returning from combat, a number of
these studies have examined the role of social support in the course of PTSD.
In one study, it was found that PTSD and depression symptoms were not
strongly associated with suicide ideation among OEF/OIF veterans with
high postdeployment social support, but that such symptoms were strongly
associated with suicide ideation among OEF/OIF veterans who reported low
postdeployment social support (DeBeer, Kimbrel, Meyer, Gulliver, &
Morissette, 2014).
Other proposed pathways from postdeployment PTSD to suicide ideation
have focused on individual psychological processes related to service
members’ exposure to combat. In line with findings pointing to moral injury
as a risk factor for PTSD, one study found that these disorders might be
associated with suicide ideation as a result of feelings of guilt experienced
by service members after they experience combat (Bryan, Roberge, Bryan, &
Ray-Sannerud, 2015). It was suggested that providing OEF/OIF veterans with
brief cognitive-behavioral therapy targeting this guilt might help reduce
suicide ideation and suicide attempts. Similarly, a more recent study of
treatment-seeking OEF/OIF veterans investigated whether trauma-related
cognitions and decreased levels of social support related to PTSD and
depression might explain why these disorders are associated with suicide
ideation. Ultimately, results indicated that the associations of both PTSD and
depression with suicide ideation could be explained by trauma-related
cognitions. However, decreases in social support related to depression could
also explain why this disorder was associated with suicide ideation (McLean
et al., 2017).
One major limitation of the studies reviewed previously, however, is that
they were based on cross-sectional data. Ramchand et al. (2015) noted the
need for more longitudinal research to better understand the temporal
sequence of mental and behavioral health problems following return from
deployment. While suicide ideation was not examined in their study, James
and her colleagues examined the relationship of predeployment stressors,
combat exposure, and postdeployment with PTSD and depression at 6, 12,
and 24 months postdeployment (James, Van Kampen, Miller, & Engdahl,
2013). Interestingly, they found that while combat exposure was associated
with PTSD at 6 months, it was not associated with symptoms at 12 or 24
months postdeployment. On the other hand, postdeployment social support
was associated with PTSD at each time point, in addition to depression at 12
and 24 months (James et al., 2013). Taken with the studies reviewed
previously, these findings emphasize the importance of considering the
psychosocial factors that may influence the risk and consequences of
postdeployment PTSD. Indeed, poor mental health after return from
deployment can impact the way service members interact with their social
environment (Karney et al., 2008). It can strain relationships with family
members (Monson, Taft, & Fredman, 2009), who often represent an
important source of social support. Because of the role social support can
play in “[facilitating] effective treatment, healing, and recovery for service
members, veterans, and their families” (Galea et al., 2012, p. 309), this may
interfere with the extent or quality of care received.

Integrative Frameworks on Postdeployment Mental

Health and Its Course
 Thus far, the present chapter has provided a review of the key findings
that have emerged from research on PTSD and its impacts among service
members deployed in support of the missions in Afghanistan and Iraq.
Population-based epidemiological research has helped gain a better
understanding of the burden militaries face in relation to postdeployment
PTSD and of specific subpopulations that are particularly at risk, while
psychological research has shed light on experiential and more dynamic
psychosocial processes that might underlie the course of PTSD. In order to
further advance theory and practice in this area, approaches are needed that
can facilitate the integration of research from both perspectives and allow
for the investigation of more dynamic processes and individual variation
while adopting the methodological rigor of epidemiological research. The
following section describes two approaches—one conceptual approach and
one methodological approach—that have recently been described in the
literature and may have the potential to do this.
In their integrated framework, Karney et al. (2008) describe some of the
consequences of deployment on mental, emotional, and cognitive health and
how these might influence service members’ and veterans’ family or social
conditions. From their perspective, postdeployment mental health conditions
such as PTSD or depression can be regarded as a source of vulnerability.
However, the specific consequences of these conditions are believed to
depend on the extent that service members and veterans have other
vulnerabilities, such as low social support or poor access to treatment or
psychosocial resources that may help them in their recovery. Longer-term
outcomes will also depend on whether service members and veterans
experience any additional stressful situations that may place further
demands on their resources. Furthermore, two mechanisms are believed to
account for the manner in which postdeployment mental health conditions
exert their ripple effects. First, the conditions may influence the way service
members and veterans interact with others around them, possibly straining
relationships with individuals who could otherwise provide needed support.
Second, changes related to mental health problems may result in an
increased risk of additional life events, such as job loss, divorce, or
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