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Frontiers in Psychology 01 frontiersin.org
Posttraumatic growth-oriented
peer-based training among U.S.
veterans: evaluation of
post-intervention and
long-term follow-up outcomes
JoshuaR.Rhodes
1, RichardG.Tedeschi
2, BretA.Moore
2,
CameronT.Alldredge
3 and GaryR.Elkins
3*
1 Department of Psychology, Abilene Christian University, Abilene, TX, United States, 2 Boulder
Crest Institute for Posttraumatic Growth, Bluemont, VA, United States, 3 Department of
Psychology and Neuroscience, Baylor University, Waco, TX, United States
Introduction: Exposure to trauma among U.S. military veterans occurs at a
high rate, often resulting in continued diculty with emotional adjustment
and a diagnosis of posttraumatic stress disorder (PTSD). The present study
provides data from 184 U.S. military veterans who completed a manualized
posttraumatic-growth oriented training program during an integrative
seven-day retreat.
Methods: Data was collected at baseline, after program completion, and at
18-month follow-up.
Results: Results on primary outcomes indicated significant increases, with
medium to large eect sizes, in growth related outcomes. Specifically, there
was a significant increase in scores by 54% on the posttraumatic growth
outcome measure (PTGI-X) from baseline (M = 50.2, SD = 31.1) to endpoint
(M = 77.4, SD = 29.6), t(183) = −8.78, p < 0.001. Also, results indicate that
immediately following training (Day 7), participants reported a significant
decrease of 49% on the PCL-5 from baseline (M = 39.7, SD = 17.6) to endpoint
(M = 20.1, SD = 13.2), t(183) = 11.75, p < 0.001. Depression subscale scores
decreased by 60% from baseline (M = 8.0, SD = 5.2) to endpoint (M = 3.2,
SD = 3.0), t(183) = 10.68, p < 0.001; Anxiety scores decreased by 28% from
baseline (M = 5.8, SD = 4.3) to endpoint (M = 4.2, SD = 3.5), t(183) = 4.08,
p < 0.001; and Stress scores decreased by 50% from baseline (M = 10.0, SD
= 4.4) to endpoint (M = 5.0, SD = 3.3), t(183) = 12.21, p < 0.001. Eighteen-
month follow-up data was available for 74 participants and indicated that all
significant changes in growth-related outcomes were maintained. Further,
all significant changes in symptomatology-related outcomes were also
maintained at follow-up.
Discussion: These findings demonstrate both the immediate and the long-
lasting impact of an integrative posttraumatic growth-oriented training
program on psychological growth and PTSD symptom reduction among
U.S. military veterans.
KEYWORDS
veterans, posttraumatic growth, trauma, posttraumatic stress disorder, Boulder
Crest Foundation
OPEN ACCESS
EDITED BY
Vittorio Lenzo,
University of Catania, Italy
REVIEWED BY
Jenny Ann Rydberg,
Université de Lorraine, France
Chiara Fioretti,
University of Salerno, Italy
*CORRESPONDENCE
Gary R. Elkins
gary_elkins@baylor.edu
RECEIVED 16 October 2023
ACCEPTED 11 December 2023
PUBLISHED 05 January 2024
CITATION
Rhodes JR, Tedeschi RG, Moore BA,
Alldredge CT and Elkins GR (2024)
Posttraumatic growth-oriented peer-based
training among U.S. veterans: evaluation of
post-intervention and long-term follow-up
outcomes.
Front. Psychol. 14:1322837.
doi: 10.3389/fpsyg.2023.1322837
COPYRIGHT
© 2024 Rhodes, Tedeschi, Moore, Alldredge
and Elkins. 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.
TYPE Original Research
PUBLISHED 05 January 2024
DOI 10.3389/fpsyg.2023.1322837
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 02 frontiersin.org
Introduction
Exposure to trauma among military veterans is very prevalent,
with approximately 87% of U.S. veterans reporting exposure to at least
one potentially traumatic event (Wisco etal., 2014). Whether or not
these reported traumatic events are directly or indirectly related to
one’s military service, evidence shows the eects of trauma are causing
veterans to experience serious diculties with emotional adjustment
(McKinney etal., 2017), resulting in 17.2 Veteran suicides per day in
2019, a number that has remained practically unchanged since 2001
(U.S. Department of Veterans Aairs, 2021). Of this population,
individuals ages 55–74 were at the highest risk, accounting for
approximately 39% of veteran deaths by suicide in 2019. A notable
diagnosis aiming to capture much of this struggle with emotional
adjustment following trauma is posttraumatic stress disorder (PTSD).
Presentation of PTSD related symptoms may vary across
individuals from distinct wars, cultures, and genders as they have been
exposed to varying specic traumas (Dutra etal., 2019). Exposure to
specic traumas results in diering duration of symptoms, perception
of treatment, and treatment response. For example, Chard etal. (2010)
found that veterans from the Vietnam war exhibited signicantly less
symptom reduction following cognitive processing therapy (CPT)
when compared to veterans from Operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF). e experience of trauma
related symptoms is also moderated by gender as men are more likely
to report trauma resulting from exposure to combat when compared
to women (Macera etal., 2014; Polusny etal., 2014) and women are
more likely to experience military sexual trauma (Haskell etal., 2010;
Kimerling etal., 2010). e high rate of comorbidity between PTSD
and other psychiatric disorders can lead to diculty in both its
diagnoses and the identication of an optimal treatment plan. For
example, while much of the current research focuses on PTSD
diagnoses, many veterans also struggle with depression and anxiety.
Studies estimate that 9.6% of veterans struggle with and receive a
diagnosis of depression (Liu et al., 2019) and the prevalence of
diagnosed anxiety disorder incidence rates varies widely from 0.01 to
23.7 per 1,000 service members (Russell et al., 2022). Dierential
diagnoses will highlight dierent aspects of PTSD symptom
presentation and require dierent treatment modalities to avoid being
ineective or exacerbating the comorbid symptoms.
e U.S. Veterans Aairs/Department of Defense (2017) clinical
practice guidelines recommend a tiered approach to PTSD treatment.
e rst recommendation cited to have the strongest evidence is
individual, manualized, trauma-focused psychotherapy. ese rst-
line therapies include Prolonged Exposure therapy (PE; Foa etal.,
2005, 2018), Cognitive Processing erapy (CPT; Resick etal., 2002),
and Eye Movement Desensitization and Reprocessing therapy
(EMDR; Shapiro, 1989; Rothbaum etal., 2005; Valiente-Gómez etal.,
2017). Second tier treatment, per the VA/DOD guidelines (2017) are
non-trauma, manualized therapies or pharmacotherapy. Non-trauma
focused, manualized therapies include stress inoculation training and
present-centered therapy. e recommended pharmacotherapies
include three selective serotonin reuptake inhibitors (SSRIs;
paroxetine, sertraline, and uoxetine) and one selective
norepinephrine reuptake inhibitor (SNRI; venlafaxine).
e current psychotherapeutic treatment modalities have seemed
to exhibit particularly high ecacy in their reduction of PTSD
symptomatology specically. Prolonged Exposure therapy has been
shown to reduce PTSD symptomatology with a pre-post eect size of
d = 0.87 (Eekhari et al., 2013). A meta-analysis of Cognitive
Processing therapy for PTSD symptom reduction found an eect size
of g = 1.24 when compared to control conditions (Asmundson etal.,
2019). Further evidence with a more broad view is found in a meta-
analysis of exposure therapies (not treatment specic), reporting a
signicant reduction in PTSD symptoms when compared to control
conditions with an eect size of g = 0.86 (McLean etal., 2022). A meta-
analysis examining the use of EMDR for PTSD symptom reduction
found an overall eect size of g = −0.64 (Chen etal., 2014). e eect
sizes found for the reduction of PTSD symptoms through
pharmacotherapy are generally much lower, with a meta-analysis
nding SSRIs to bestatistically superior to placebo administration but
with a small eect size (d = 0.23; Hoskins etal., 2015). While the
evidence indicates that individuals can benet from trauma-focused,
manualized therapies, the consensus on whether they signicantly
outperform non-trauma-focused therapies has been called into
question. Recent studies have exhibited mixed-results as to whether
patients are receiving clinically meaningful benet from rst-line
therapies such as PE and CPT (Steenkamp etal., 2020). Furthermore,
these rst-line therapies have been found to beonly marginally
superior to non-trauma focused therapies and active control groups
(Steenkamp etal., 2015). While these rst-line therapies provide great
benet for some, they are not without their limitations, namely high
nonresponse, underresponse, and dropout rates among participants
(Steenkamp etal., 2020). Together these ndings indicate that the
highly complex nature of PTSD and the management of these
symptoms within a military population may not bea good match for
a one-size-ts-all treatment approach (Steenkamp etal., 2020).
e framework of clinical work with military veterans has largely
been focused on the identication of PTSD symptoms and symptom
reduction following trauma exposure. e identication of the
individual’s struggle and the goal of reducing their suering are not
only admirable, but are essential for providing help to countless
veterans. e current model of PTSD and its treatment has proven to
beecacious in the reduction of PTSD specic symptoms but seems
to fall short in addressing the existential needs and issues veterans
face. e diculty engaging veterans in long-term treatment across
months has led to decreased satisfaction across treatment modalities,
even though their completion seems to promise signicant symptom
reduction (Kehle-Forbes etal., 2016; Smith etal., 2019). Alternatively,
intensive treatment programs (one or two weeks) have been examined
as a potential way to improve on the high dropout rate and limited
engagement among individuals (Hendriks etal., 2018; Watkins etal.,
2018). While the evidence indicates that massed, trauma-focused
therapies are benecial (Hendriks etal., 2018), they do not directly
address the potential for posttraumatic growth and there is limited
research on intensive treatment programs inuenced by posttraumatic
growth theory.
Posttraumatic growth (PTG) is dened as positive psychological
changes that can beexperienced as a result of the struggle in the
aermath of traumatic or highly challenging circumstances (Tedeschi
etal., 2018). Posttraumatic growth theory, largely inuenced by Jano-
Bulman (1989), assumes that trauma involves emotional distress as a
result of core beliefs being shattered following traumatic events. e
disruption of the core belief system leads to struggle and the potential
for transformative outcomes and growth. e concept of struggle
refers to the diculties encountered in the process of reconstructing
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 03 frontiersin.org
one’s core beliefs. e struggle and distress can oen prompt
deliberative rumination within the individual. When paired with
disclosure to a trusted individual, this deliberative rumination can aid
in the process of reconceptualizing one’s core belief system (Tedeschi
and Moore, 2021).
Posttraumatic growth has been shown to exhibit itself in ve
domains across individuals (Tedeschi and Calhoun, 1996; Tedeschi
et al., 2017). is ve-factor model has been established through
factor analysis of the posttraumatic growth inventory (PTGI; Tedeschi
and Calhoun, 1996; Tedeschi etal., 2017) and several other studies
(Linley etal., 2007; Taku etal., 2008; Brunet etal., 2010; Lee etal.,
2010). e ve domains identied in prior research include: Relating
to Others, Personal Strength, Appreciation of Life, New Possibilities,
and Spiritual-Existential Change.
e domain of Relating to Others in PTG reects a deeper
emotional quality to relationships, oen paired with an increased
sense of mutual respect, disclosure, openness, and compassion (Moore
et al., 2021). As trauma survivors disclose their experiences, an
empathic listener can bevery important in the process (Tedeschi and
Calhoun, 2006).
e domain of Personal Strength is oen exhibited aer the
individual has simply managed to survive the trauma and its
aermath. Reection on the experience can instill a greater sense of
personal strength as they recognize the self-reliance and courage it
took to reach where they are (Tedeschi and Calhoun, 1996; Moore
etal., 2021).
Appreciation of Life includes a new perspective that allows the
individual to experience a new sense of gratitude for things previously
overlooked. is increased sense of appreciation is oen the result of
actual loss or having narrowly escaped the loss (Tedeschi and Calhoun,
1996; Moore etal., 2021).
Traumatic experiences involve loss of things such as capabilities,
roles, relationships and alter an anticipated future. In the struggle to
deal with such signicant loss, it is possible that new ways to live are
discovered. e recognition of new possibilities for a positive future
may beessential to developing PTG (Roepke and Seligman, 2015). e
search for fulllment in areas previously unconsidered, is referred to
as the domain of New Possibilities (Tedeschi and Calhoun, 1996;
Moore etal., 2021).
e domain of Spiritual-Existential Change may occur when
individuals reconsider existential issues and potentially recongure
their beliefs and belief systems as a result of their experience with
trauma (Tedeschi and Calhoun, 1996; Moore etal., 2021). e impact
of traumatic events can cause survivors to consider existential
questions such as life meaning and purpose (Tedeschi and Rie,
2016). Also, for many survivors of trauma, considerations of
forgiveness, spirituality, and religious beliefs may bean important
component of PTG (Schultz etal., 2010).
Rather than being a new form of therapy, PTG-based intervention
is an integrative approach that utilizes elements and research
knowledge drawn from several existing approaches, specically:
cognitive-behavioral, narrative, existential, and interpersonal.
PTG-based intervention acknowledges the evolving evidence base for
trauma interventions within a philosophy that proposes that trauma
survivors can both achieve symptom reduction and experience
transformative posttraumatic growth (Tedeschi and Moore, 2021) in
the ve domains of PTG. It is not simply focused on symptom
reduction (although PTG-based intervention may result in reduced
trauma related symptoms), but promotes and emphasizes the
importance of managing emotional distress and moving toward
growth that would not have been likely if not for the struggle with the
traumatic events. e PTG model of intervention is unique in the
emphasis on PTG, but also integrates four primary elements of
existing approaches listed below.
Cognitive-behavioral interventions identify change in core
beliefs and cognitions as underlying mechanisms of change. Core
beliefs may be formulated in early life and people oen make
assumptions about themselves and the world that may go
unexamined until encountering trauma that disrupts one’s
“assumptive world” (Jano-Bulman, 1989). erefore, the PTG
intervention model is directed toward schema change (Jano-
Bulman, 2006) using a variety of methods. e process of
reconstructing one’s core belief system is an evidence-based
approach that is a foundation for cognitive processing therapy
(Resick etal., 2008) as well as PTG-based intervention. Further,
many trauma survivors must achieve a sucient degree of emotional
regulation before being able to tolerate the emotional stress
associated with schema change. erefore, psychoeducation about
trauma reactions and teaching emotional regulation methods (i.e.,
relaxation, mindfulness, present-moment awareness, etc.) are an
integral component of the PTG integrative intervention approach.
PTG-based intervention also integrates the concept of developing
a new life narrative into it’s approach. With the revision of core beliefs,
trauma survivors are oen tasked with making personal decisions
about what kind of life they wish to have in the future and
incorporating the past trauma into their personal narrative of their
past, present, and future. Narrative therapies, such as those delivered
through expressive writing and reection have been shown to have
positive eects on PTG (Hijazi et al., 2014). Interventions that
integrate narrative development have been shown to beof benet with
a range of trauma survivors (Neimeyer, 2006; Smyth etal., 2008).
Along with core belief and narrative examination, the struggle
with the aermath of trauma oen leads to an awareness of existential
questions such as meaning and purpose of trauma and their lives.
Survivors may struggle with questions about fairness, justice, and
nding new meaning and purpose following signicant loss (Frankl,
1962). e existential element is drawn from the concepts within
logotherapy and existential therapy generally (Tedeschi and Rie,
2016). Examination of existential issues is deliberately addressed
within the PTG-based approach.
Interpersonal and “common factors” have been shown to
besignicant components of most psychotherapeutic interventions
(Norcross and Wampold, 2011). In the PTG-based intervention,
individuals called “expert guides” are individuals trained in providing
a supportive environment, non-judgmental listening, unconditional
positive regard, and activities toward promoting growth beyond
symptom reduction (Calhoun and Tedeschi, 2013). is interpersonal
element provides the foundation for trauma survivors to expand their
support system, construct new core beliefs, and personal narrative that
promotes posttraumatic growth.
PTG-based intervention is provided by individuals trained in
providing “expert companionship” oen referred to as “expert guides.”
PTG-based intervention is conceptualized as a training program that
follows the natural process following the aermath of trauma. e
goals are not limited to symptom reduction, but include managing
distress, and achieving growth in multiple domains. ere are ve
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 04 frontiersin.org
general components in the structure of PTG-based intervention
(Calhoun and Tedeschi, 2013).
Psychoeducation is provided regarding how trauma symptoms
develop (Barlow, 2014) and understanding distressing symptoms
(Meichenbaum, 2012). Further, psychoeducation is provided
regarding the potential of PTG, the domains of PTG, and sharing
personal examples. is includes a discussion of how core beliefs have
been disrupted and how a reconceptualization and development of
new core beliefs can betransformative toward living well and thriving
in the aermath of trauma (Calhoun and Tedeschi, 2013; Tedeschi and
Moore, 2021). In addition, assurance about facing and addressing
existential questions is provided within a caring and non-judgmental
interpersonal relationship.
Teaching and practicing methods of emotional regulation is
integrated throughout the structure of PTG-based intervention. is
includes relaxation, focus on breathing, grounding techniques,
mindfulness exercises, meditation, relaxed music listening, and
exercise. Experiential practice is demonstrated and emphasized over
intellectual understanding of these emotional regulation techniques.
It is benecial to allow survivors to experience a variety of ways to
regulate emotions and select personal preferences to apply to their
own lives (Cooper etal., 2019).
Disclosure is essential within the PTG-based intervention
structure. Disclosure is modeled by the “expert guides” and a safe and
supportive environment is fostered. However, in contrast to exposure-
based therapies (Peterson etal., 2019), the disclosure is not focused on
the specics of the traumatic events, but on the impact of these events
on the individual’s core belief system about self, others, the world, and
the future (Williams etal., 2019). Disclosure about one’s personal life
story broadly dened is encouraged within a non-judgmental context.
Openness to sharing key personal life events, inuences, successes,
perceived failures, and decreasing defensiveness are important aspects
of self-reection and a sense of being accepted.
Development of a personal “life story” brings together an
understanding of key past experiences, perhaps extending into
childhood. It is not simply disclosure about the traumatic event.
Rather, the development of the survivor’s personal story includes the
trauma in the context of entire past and future. It includes looking
forward and consideration of new possibilities for the future and new
ways of understanding the past. e narrative may bring up past
events, regrets, guilt, or unresolved anger. Some aspects may require
acceptance and other change in moving toward the future with
growth. Development of a new “life story” narrative is achieved with
the support of the “expert guide” and in the process of disclosure.
As posttraumatic growth occurs, survivors may have new insights,
goals, sense of meaning and purpose. An awareness of ways they can
support the growth of others who may have experienced their own
traumas, leads to a stronger connection with family and community.
is can bemanifested in new goals in life and awareness of service to
help others and sharing their experience of PTG.
e Warrior PATHH (Progressive and Alternative Training for
Helping Heroes) program is the agship program of the Boulder
Crest Foundation (BCF), a non-prot organization focused on the
psychological health of U.S. veterans. e Warrior PATHH program
is a 7 days intensive residency program developed to provide
PTG-based training and experiences to veterans. e program
consists of 48 psychoeducational modules, which are described in a
200-page guide developed for program instructors. Although the
program does not oer traditional, evidenced-based psychotherapies,
the program does utilize a variety of complementary and alternative
interventions (e.g., mindfulness/meditation, yoga, equine therapy)
and traditional psychotherapeutic techniques (e.g., psychoeducation,
distress management, relationship building, narrative development,
goal setting). A unique aspect of Warrior PATHH is that it is peer-
delivered and is not run or managed by mental health professionals.
is is an important component of the program as those working
within Warrior PATHH are veterans who understand the unique
needs and professional culture of those who attend the program. e
peers who deliver the bulk of the program are combat veterans who
have undergone several months of training from peer leaders with
years of experience delivering the program as well as licensed mental
health professionals. Peers delivering the program receive ongoing
training and consultation from these same peer leaders and
professionals. Consequently, Warrior PATHH is considered a training
program as opposed to a treatment program. Following the
residential portion of the program, a structured 18 months of
follow-up is oered through a web-based series of meetings and
assignments. A more complete description of the Warrior PATHH
program can befound in Moore etal. (2021).
While the PTG-based intervention approach of Warrior PATHH
has been well developed and manualized, to date there has been
limited outcome research. A small pilot study of the Warrior PATHH
posttraumatic growth-based intervention program found signicant,
large reductions in symptomatology including PTSD, insomnia, and
negative aect (Moore etal., 2021). Additionally, results indicated
signicant increases in areas of PTG and psychological exibility.
While these results are encouraging, they do not report immediate
outcomes of study participants, resulting in the inability to gather a
full picture of immediate and long-term eects. Without the report of
immediate outcomes, one does not know about the trajectory of
benet to participants and cannot determine any lasting changes. e
purpose of the present study was to address this gap in research by
conducting a retrospective evaluation of a much larger sample of
veterans with PTSD symptoms who completed the Warrior PATHH
program. Outcome data were collected at baseline, aer the 7 day
program was completed, and at 18 months follow-up.
Method
Participants were UnitedStates combat Veterans completing the
Warrior PATHH program. Participants were self-referred and most
commonly learned about the program from other veterans and family
members familiar with the training program. Participation in the
training program was free of cost to all participants and they received
no compensation for completing the training. Inclusion criteria for the
Warrior PATHH program were individuals who were (1) U.S. military
Veterans and (2) had a previous history of trauma. Individuals were
excluded from participation if they (1) were diagnosed with any
disorder that might require hospitalization, such as psychosis,
substance abuse, or active suicidality.
Data collection for all participants occurred prior to the initiation of
the program (Day 0), which will bereferred to as baseline; at the end of
the training (Day 7), which will bereferred to as endpoint; and 18 months
following the completion of training, which will be referred to as
follow-up. e formal evaluation at baseline, endpoint, and follow-up was
completed through the administration of an electronic questionnaire. A
selection of measurements relating to growth and symptomatology
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 05 frontiersin.org
domains are reported in this manuscript. All measurement tools listed
were collected at baseline, endpoint, and 18-month follow-up.
Measures
Posttraumatic Growth Inventory – Expanded (PTGI-X). e
PTGI-X (Tedeschi etal., 2017) is a 25-item self-report measure used
to assess the extent to which individuals report positive psychological
change following the experience of a traumatic event. Five subscales
of this measure assess changes in one’s perception of new possibilities,
relating to others, personal strength, appreciation of life, and spiritual-
existential change. Individual items are on a 6-point Likert scale
ranging from “I did not experience this change” to “I experienced this
change to a very great degree.” Good internal consistency (α = 0.90;
Tedeschi etal., 2017) and content validity has been shown in research
(Shakespeare-Finch etal., 2013).
Positive and Negative Aect Schedule (PANAS). e PANAS
(Watson etal., 1988) is a 20-item self-report measure for both positive
and negative aect. Individual item responses are on a 5-point
frequency scale ranging from “not at all” to “extremely.” Strong
reliability for both the positive (α = 0.89) and negative subscale
(α = 0.85) and construct validity has been reported in addition to
substantial available normative data (Crawford and Henry, 2004).
Integration of Stressful Life Experiences Scale (ISLES). e
ISLES (Holland etal., 2010) is a 16-item self-report measure used to
assess the extent of meaning made following a stressful life experience.
Individual items are on a 5-point Likert scale ranging from “strongly
agree” to “strongly disagree.” e ISLES has exhibited strong internal
consistency, strong convergent validity, and moderate test–retest
reliability (Holland etal., 2010).
Posttraumatic Stress Disorder Checklist DSM 5 (PCL-5). e
PCL-5 (Weathers etal., 2013) is a 20-item self-report measure assessing
DSM-5 symptoms of PTSD. Individual item responses are on a 5-point
frequency scale ranging from “not at all” to “extremely.” Strong construct
validity (α = 0.92) and test–retest reliability (r = 0.57) has been found in
veteran samples (Bovin etal., 2015; Dutra etal., 2019).
Depression, Anxiety, and Stress Scale (DASS). e DASS (Antony
etal., 1998) is a 21-item self-report measures of the presence and degree
of depression, anxiety, and stress-related symptoms. Individual item
responses are on a 4-point frequency scale ranging from “never” to
“almost always.” Adequate test–retest reliability (α = 0.86–0.90; Gloster
etal., 2008) in addition to discriminate and convergent validity has been
shown in clinical samples (Brown etal., 1997).
Insomnia Severity Index (ISI). e ISI (Bastien etal., 2001) is a
7-item self-report measure, based on DSM-IV and the International
Classication of Sleep Disorders criteria, used to assess insomnia over
the past 2 weeks. Individual items are assessed on a 5-point Likert
scale ranging from “none” to “very severe.” High reliability and validity
have been shown for the ISI in both clinical (α = 0.91) and community
(α = 0.90) samples (Morin etal., 2011).
Intervention
Framed as an intensive training program for veterans, the evaluated
program is the Warrior PATHH (Progressive and Alternative Training
for Helping Heroes). e manualized, 7 days training program is based
on posttraumatic growth theory and its intervention model (Tedeschi
and McNally, 2011; Calhoun and Tedeschi, 2013; Tedeschi and Moore,
2016, 2018). During this 7 days period, participants are immersed in an
all-day intensive regimen combining education and experiential
activities. Participants who attend the Warrior PATHH program
experienced the following ve elements in accordance with the PTG
model: psychoeducation about physiological and psychological trauma
response and psychological growth; emotion regulation training,
including mindfulness and meditative techniques; constructive self-
disclosure about trauma and its aermath that occurs naturally through
casual discourse; non-trauma focused narrative development
integrating perspectives of past, present, and future; and service goals
that are developed to carry out the lessons learned about the value of
life, living courageously, and understanding those who have not had the
same experiences (Moore et al., 2021). Representing a relational
approach to the intervention called Expert Companionship, those
providing the intervention are referred to as “expert guides.” All expert
guides that were responsible for delivering the intervention were
U.S. combat veterans who underwent several months of training with
established expert guides and mental health professionals trained in the
PTG-based intervention. Delivered as a peer-to-peer training program,
the Warrior PATHH program took place during a 7 days period at the
BCF facility in Bluemont, Virgina, between February 2019 and
December 2021.
Analyses
Descriptive statistics at baseline, endpoint, and follow-up were
calculated for each of the outcome measures. To determine immediate
post-intervention eects, paired samples t-tests were conducted for
each outcome. Paired samples t-tests are used to determine the
statistical signicance of the dierence in scores on outcome measures
from baseline to endpoint. e independent variable in these analyses
was study time point which had two levels, baseline (Day 1) and
endpoint (Day 7). Dependent variables in these analyses were growth
domains, including posttraumatic growth, positive aect, and
integration of stressful life experiences; and symptomatology domains,
including PTSD symptoms, depression, anxiety, stress, negative aect,
and insomnia.
To determine the lasting eects of the Warrior PATHH program
on growth and symptomatology domains a series of repeated measures
analysis of variance (repeated measures ANOVA) were conducted,
which are extensions of the paired-samples t-tests. e independent
variable for these repeated measures ANOVAs was “time” (baseline,
endpoint, and follow-up). e dependent variables for these repeated
measures ANOVAs were the specic outcome measures. In the event
of a signicant main eect of time, pairwise comparisons using a
Bonferroni correction were examined to determine dierences
between specic study time points.
To determine the moderating eect of gender on immediate and
lasting post-intervention eects on growth and symptomatology
domains, multiple analyses of covariance (ANCOVA) were conducted.
e independent variable for these ANCOVAs examining immediate
eects was “gender,” the dependent variables were the scores on the
specic outcome measures at endpoint, and the covariates were the
baseline score of the specic outcome. e independent variable for
the ANCOVAs examining lasting eects was “gender,” the dependent
variables were the scores of the specic outcome measure at follow-up,
and the covariates were the endpoint score of the specic outcome.
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 06 frontiersin.org
Results
Participants were 184 United States combat veterans
(male = 155, female = 29) who completed the Warrior PATHH
training program between February 2019 and December 2021. e
most common U.S. military branch of service represented was
Army (n = 110), with the second most frequent being Marine
Corps. (n = 32). Frequencies of all participant demographic
variables can befound in Table1.
All participants (n = 184) provided complete data at baseline
and endpoint and were included in all analyses examining post-
intervention changes. At the optional 18 months follow-up time
point, 74 individuals completed outcome measures. Due to the
nature of the statistical analyses examining long-term changes,
only the 74 individuals who provided data at all three time points
were included in the analyses of long-term changes at 18 months.
Post-intervention changes in growth
domains
A paired samples t-test was used to compare scores on each
growth-related outcome variable between baseline and endpoint.
Results indicate that immediately following training (Day 7),
participants reported a signicant increase in scores by 54% on the
posttraumatic growth outcome measure (PTGI-X) from baseline
(M = 50.2, SD = 31.1) to endpoint (M = 77.4, SD = 29.6), t(183) = −8.78,
p < 0.001. Additionally, there was a signicant increase in scores by
45% on the positive aect subscale of the PANAS from baseline
(M = 25.8, SD = 8.4) to endpoint (M = 37.5, SD = 6.9), t(183) = −14.84,
p < 0.001. Finally, there was a signicant increase in scores by 29% on
the ISLES from baseline (M = 39.2, SD = 12.9) to endpoint (M = 50.4,
SD = 10.9), t(183) = −9.13, p < 0.001. Table2 contains calculated eect
sizes for each paired sample comparison.
Results from paired samples t-tests for scores on each
subscale of the PTGI-X indicate a significant difference between
baseline and endpoint for New Possibilities (M = 10.6, SD = 7.3,
M = 15.7, SD = 6.3, respectively), t(183) = −7.13, p < 0.001;
Personal Strength (M = 8.9, SD = 5.9, M = 13.8, SD = 4.8,
respectively), t(183) = −9.01, p < 0.001; Appreciation of Life
(M = 8.22, SD = 4.2, M = 9.7, SD = 3.9, respectively),
t(183) = −3.71, p < 0.001; Relating to Others (M = 12.6, SD = 9.6,
M = 21.5, SD = 9.5, respectively), t(183) = −9.47, p < 0.001; and
Spiritual-Existential Change (M = 10.0, SD = 8.4, M = 16.6,
SD = 8.5, respectively), t(183) = −7.54, p < 0.001. Medium effect
sizes were found for scores on the subscales of Relating to Others
(Cohen’s d = −0.70), Personal Strength (Cohen’s d = −0.66),
Spiritual-Existential Change (Cohen’s d = −0.56), and New
Possibilities (Cohen’s d = −0.53), and there was a small effect size
for scores on Appreciation of Life subscale (Cohen’s d = −0.27).
Post-intervention changes in
symptomatology domains
Next, a paired samples t-test was used to compare scores on
each symptomatology-related outcome variable between baseline
and endpoint. Results indicate that immediately following training
(Day 7), participants reported a signicant decrease in scores by
49% on the PCL-5 from baseline (M = 39.7, SD = 17.6) to endpoint
(M = 20.1, SD = 13.2), t(183) = 11.75, p < 0.001. A signicant
decrease in scores was reported for all subscales of the
DASS. Depression subscale scores decreased by 60% from baseline
(M = 8.0, SD = 5.2) to endpoint (M = 3.2, SD = 3.0), t(183) = 10.68,
p < 0.001; anxiety subscale scores decreased by 28% from baseline
(M = 5.8, SD = 4.3) to endpoint (M = 4.2, SD = 3.5), t(183) = 4.08,
p < 0.001; and stress subscale scores decreased by 50% from
baseline (M = 10.0, SD = 4.4) to endpoint (M = 5.0, SD = 3.3),
t(183) = 12.21, p < 0.001. Participant scores on the ISI signicantly
decreased by 36% from baseline (M = 14.3, SD = 6.9) to endpoint
(M = 9.1, SD = 5.3), t(183) = 8.03, p < 0.001. Finally, scores on the
negative aect subscale of the PANAS signicantly decreased by
16% from baseline (M = 25.4, SD = 8.2) to endpoint (M = 21.4,
SD = 7.4), t(183) = 4.89, p < 0.001. Table3 contains calculated eect
sizes for each paired sample comparison.
TABLE1 Participant demographics.
Demographic variable Frequency
Gender
Male 155
Female 29
Age range
23–27 3
28–32 15
33–37 46
38–42 43
43–47 24
48 or older 53
Branch of service
Air Force 18
Army 110
First Responder 12
Marine Corps 32
Navy 12
Military Rank
E1–E4 32
E5–E6 69
E7 or above 41
Ocer/Warrant Ocer 31
Not specied 11
TABLE2 Growth domains eect sizes.
Outcome Eect Size (d)
PTG −0.65
Positive aect −1.09
ISLES −0.67
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Frontiers in Psychology 07 frontiersin.org
Long term changes in growth domains
A series of independent samples t-tests were rst conducted to
determine if the 74 participants who completed follow-up
measures were representative of the entire sample. e test variable
for each of these analyses was the baseline score of each outcome
measure. e grouping variable used was (A = Participants who
completed baseline and endpoint data; n = 110) and
(B = participants who completed follow-up measures; n = 74).
Results of these t-tests indicate that there were no signicant
dierences between groups on any outcome measure at baseline,
with the exception of baseline depression (Mean Dierence = 1.59,
p = 0.041) and baseline ISLES (Mean Dierence = 4.32, p = 0.023)
scores. Overall, these ndings suggest a follow-up sample
representative of the entire sample.
A series of repeated measures ANOVAs were then conducted to
examine changes in growth-related outcome measures over three
time points (baseline, endpoint, and follow-up). e analysis on
PTGI-X scores revealed a signicant main eect of time,
F(2,146) = 21.26, p < 0.001. Pairwise comparisons indicate that
PTGI-X scores signicantly increased by 27.1 points (52%) from
baseline to endpoint (p < 0.001) and remained stable until follow-up,
exhibited by a further increase of 0.85 points (p = 1.00) and a total
increase of 54% between baseline and follow-up. e analysis on
positive aect subscale scores also revealed a signicant main eect
of time, F(2,146) = 56.09, p = <0.001. Pairwise comparisons indicate
that scores on the positive aect subscale signicantly increased by
11.1 points (41%) from baseline to endpoint (p < 0.001). Results
indicate that between endpoint and follow-up, positive aect subscale
scores signicantly decreased by 8.2 points (p < 0.001); however, there
remained a signicant dierence between baseline and follow-up
scores (p = 0.010) exhibited by a total increase of 11% between
baseline and follow-up. Regarding the analysis on ISLES scores,
Mauchly’s test indicated that the assumption of sphericity had been
violated, χ
2
(2) = 6.70, p = 0.035, therefore the degrees of freedom were
corrected using Greenhouse-Geisser estimates of sphericity
(ε = 0.918). e results indicate a signicant main eect of time,
F(1.84, 134.09) = 23.99, p < 0.001. Pairwise comparisons indicate that
ISLES scores signicantly increased by 9.69 points (23%) from
baseline to endpoint (p < 0.001) and remained stable until follow-up,
exhibited by a non-signicant increase of 1.42 points (p = 1.00) and a
total increase of 27% from baseline to follow-up. Table4 includes
means and standard deviations for each growth-related outcome
measure at each time point.
e analyses on PTGI-X subscale scores revealed a signicant
main eect of time for Appreciation of Life, F(2,146) = 3.25, p = 0.041;
Personal Strength, F(2,146) = 24.66, p < 0.001; New Possibilities,
F(2,146) = 13.91, p < 0.001; Relating to Others F(1.81, 131.96) = 24.21,
p < 0.001; and Spiritual-Existential Change, F(1.75, 127.84) = 17.96,
p < 0.001. Mauchly’s test indicated that the assumption of sphericity
had been violated for the scores on subscales Relating to Others, χ2
(2) = 8.10, p = 0.017, and Spiritual-Existential Change, χ
2
(2) = 11.03,
p = 0.004, therefore the degrees of freedom were corrected using
Greenhouse-Geisser estimates of sphericity (ε = 0.904, ε = 0.876;
respectively). Pairwise comparisons indicate that all subscales with a
signicant main eect of time, with the exception of the Appreciation
of Life subscale, exhibited a signicant increase in scores from
baseline to endpoint, followed by stability through follow-up. is
stability through follow-up was exhibited by a non-signicant
decrease in scores for Personal Strength and New Possibilities
subscales and by a non-signicant increase in scores for the Relating
to Others and Spiritual-Existential Change subscales. Table5 includes
TABLE3 Symptomatology domains eect sizes.
Outcome Eect Size (d)
PTSD 0.87
Depression 0.79
Anxiety 0.30
Stress 0.90
Insomnia 0.59
Negative aect 0.36
TABLE4 Long-term changes in growth domains.
Outcome Baseline Endpoint Follow-up
Mean SD Mean SD Mean SD
PTG 52.03 29.20 79.12 30.47 79.97 31.40
Positive Aect 27.20 7.94 38.26 5.74 30.09 7.98
ISLES 41.66 11.60 51.35 10.49 52.77 9.86
TABLE5 Long-term changes in PTGI-X subscales.
Outcome Baseline Endpoint Follow-up
Mean SD Mean SD Mean SD
Appreciation of Life 8.35 4.20 9.89 3.87 9.69 4.04
Personal Strength 8.76 5.49 13.95 5.00 13.65 5.30
New Possibilities 10.73 7.60 16.00 6.46 15.93 6.87
Relating to Others 13.62 8.78 22.34 9.37 22.68 9.28
Spiritual-Existential Change 10.57 8.42 16.95 8.89 18.03 8.43
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Frontiers in Psychology 08 frontiersin.org
means and standard deviations for each PTGI-X subscale at each
time point.
Long term changes in symptomatology
domains
A series of repeated measures ANOVAs were conducted to
examine changes in symptomatology-related outcome measures
over three time points (baseline, endpoint, and follow-up). Mauchly’s
Test of Sphericity indicated that the assumption of sphericity had
been violated for PCL-5 scores, χ
2
(2) = 15.82, p < 0.001, depression
scores, χ
2
(2) = 23.17, p < 0.001, anxiety scores, χ
2
(2) = 12.80,
p = 0.002, ISI scores, χ
2
(2) = 12.91, p = 0.002, and negative aect
scores, χ2 (2) = 11.52, p = 0.003, and therefore a Greenhouse-Geisser
correction was used for each of these analyses. e analysis of PCL-5
scores revealed a signicant main eect of time, F(1.67, 146) = 33.87,
p < 0.001. Pairwise comparisons indicate that PCL-5 scores
signicantly decreased by 15.66 points (43%) from baseline to
endpoint (p < 0.001) and remained stable until follow-up, exhibited
by a further decrease of 2.43 points (p = 1.00) and a total decrease of
49% from baseline to follow-up. e analysis of depression subscale
scores revealed a signicant main eect of time, F(1.57,
114.49) = 21.05, p < 0.001. Pairwise comparisons indicate that
depression subscale scores signicantly decreased by 3.37 points
(48%) from baseline to endpoint (p < 0.001) and remained stable
until follow-up, exhibited by a further decrease of 0.31 points
(p = 1.00) and a total decrease of 53% from baseline to follow-up. e
analysis of anxiety subscale scores revealed a signicant main eect
of time, F(1.72, 125.55) = 9.09, p < 0.001. Pairwise comparisons
indicate that anxiety subscale scores did not signicantly decrease
from baseline to endpoint (p = 0.534), but did signicantly decrease
by 1.55 points from endpoint to follow-up (p = 0.029) resulting in a
total decrease of 45% from baseline to follow-up. e analysis of
stress subscale scores revealed a signicant main eect of time, F(2,
146) = 29.30, p < 0.001. Pairwise comparisons indicate that stress
subscales scores signicantly decreased by 4.22 points (44%) from
baseline to endpoint (p < 0.001) and remained stable until follow-up
exhibited by a non-signicant further decrease in scores by 0.04
points (p = 1.00) and a total decrease of 44% from baseline to
follow-up. e analysis of ISI scores revealed a signicant main eect
of time F(1.72, 125.42) = 15.60, p < 0.001. Pairwise comparisons
indicate ISI scores signicantly decreased by 4.38 points (32%) from
baseline to endpoint (p < 0.001) and remained stable until follow-up,
exhibited by a non-signicant further decrease in scores by 0.32
points (p = 1.00) and a total decrease of 34% from baseline to
follow-up. e analysis of negative aect subscale scores revealed a
signicant main eect of time F(1.74, 127.19) = 20.33, p < 0.001.
Pairwise comparisons indicate that negative aect subscale scores
did not signicantly decrease from baseline to endpoint (p = 0.674),
but did signicantly decrease by 5.00 points from endpoint to
follow-up (p < 0.001), resulting in a total decrease of 27% from
baseline to follow-up. Table 6 includes means and standard
deviations for each symptomatology measure at each time point.
Gender dierences in post-intervention
outcomes
Multiple one-way ANCOVAs were conducted to determine a
statically signicant dierence between male and female participants
on each growth and symptomatology-related outcome measure at
endpoint, controlling for participant baseline scores. Aer adjustment
for pre-intervention scores, there was only one outcome measure,
DASS anxiety subscale scores, that resulted in a statistically signicant
dierence in post-intervention scores between male and female
participants, F(1, 181) = 4.17, p = 0.043, partial η2 = 0.023. Analysis of
covariance results, in addition to adjusted means and standard errors,
for all outcome measures can befound in Table7.
Gender dierences in long-term outcomes
Finally, multiple one-way ANCOVAs were conducted to
determine a statistically signicant dierence between male and
female participants on each growth- and symptomatology-related
outcome measure at follow-up, controlling for participant endpoint
scores. Aer adjustment for endpoint scores, no outcome measure at
follow-up indicated a statistically signicant dierence between male
and female participants. Analysis of covariance results, in addition to
adjusted means and standard errors, for all outcome measures at
follow-up can befound in Table8.
Discussion
e present study examined the impact of a manualized,
posttraumatic growth-oriented training program on various growth
and symptomatology-related outcome variables among U.S. military
veterans. e utilized training program, the Warrior PATHH program,
TABLE6 Long-term changes in symptomatology domains.
Outcome Baseline Endpoint Follow-Up
Mean SD Mean SD Mean SD
PTSD 36.80 18.20 21.14 13.05 18.70 14.20
Depression 6.99 5.27 3.62 3.25 3.31 3.74
Anxiety 5.55 4.47 4.62 3.89 3.07 3.35
Stress 9.68 4.59 5.46 3.33 5.42 4.09
Insomnia 13.77 7.29 9.39 5.51 9.07 5.74
Negative Aect 24.00 7.59 22.51 6.48 17.51 6.87
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Frontiers in Psychology 09 frontiersin.org
is not conceptualized as a psychotherapeutic intervention. Rather, this
manualized training program is peer based and developed to help
veterans develop the tools necessary to increase their capacity to
regulate thoughts, emotions, and actions in a civilian environment.
e primary focus of the Warrior PATHH training is the facilitation
of PTG and its ve domains. However, the integrated nature of the
training means that many elements of empirically based PTSD
treatments have been incorporated into the design. e incorporation
of these elements implies that completion of the training program
should also have an impact on the presentation of PTSD
related symptomatology.
Post-intervention outcomes
In accordance with our hypotheses regarding immediate post-
intervention changes, ndings revealed signicant improvements on all
growth-related outcome measures immediately following the training.
Specically, participants reported a 54% increase in scores on the
posttraumatic growth inventory (PTGI-X) from baseline to endpoint,
indicating that participants experienced a noteworthy enhancement in
their perception of posttraumatic growth-related domains in the
aermath of the training. Further evidence of this growth is exhibited
by signicant improvements on all ve subscales of the
PTGI-X. Similarly, a signicant increase in scores was observed for the
positive aect subscale of the PANAS, exhibited by a 45% increase in
scores from baseline to endpoint. is suggests that participants
experienced notable improvement in their overall positive emotional
states following the training. Finally, ndings revealed a signicant
increase in scores on the ISLES from baseline to endpoint by 29%,
indicating that participants are able to report an increased sense of
meaning following their previous trauma exposure. e observed eect
sizes for each paired sample comparison, as presented in Table2, further
support the robustness of this study’s ndings. e magnitude of change
found in each growth-related outcome variable provides additional
evidence for the meaningful impact of training program on participants
self-reported experiences. Overall, the results provide strong empirical
support for the eectiveness of the Warrior PATHH training program
in promoting posttraumatic growth, positive aect, and the integration
of stressful experiences immediately following training.
While the program was not focused on treatment, it is very
noteworthy that participants reported signicant reduction of
PTSD symptomatology scores by 49% from baseline to endpoint.
is suggests a notable alleviation of PTSD related symptoms
among participants. Additional signicant reductions were found
for depression (60%), anxiety (28%), and stress (50%) scores from
TABLE7 Eect of gender on post-intervention outcomes.
Outcome Male (n = 155) Female (n = 29) F p partial η2
MeanaSE MeanaSE
PTG 77.26 2.40 77.89 5.58 0.011 0.918 0.000
Positive Aect 37.47 0.56 37.51 1.29 0.001 0.976 0.000
ISLES 50.36 0.88 50.82 2.05 0.042 0.838 0.000
PTSD 20.58 1.06 17.41 2.47 1.38 0.242 0.008
Depression 3.34 0.24 2.39 0.56 2.38 0.125 0.013
Anxiety 4.45 0.28 3.00 0.65 4.17 0.043 0.023
Stress 5.19 0.26 4.00 0.61 3.22 0.074 0.017
Insomnia 9.21 0.43 8.17 1.00 0.923 0.338 0.005
Negative Aect 21.66 0.60 19.69 1.39 1.70 0.194 0.009
aAdjusted means aer controlling for baseline scores are presented.
TABLE8 Eect of gender on long-term outcomes.
Outcome Male (n = 63) Female (n = 11) F p partial η2
MeanaSE MeanaSE
PTG 79.77 3.98 81.13 9.52 0.017 0.896 0.000
Positive Aect 29.93 1.02 31.01 2.44 0.167 0.684 0.002
ISLES 52.05 1.23 56.90 2.94 2.33 0.132 0.032
PTSD 19.56 1.79 13.80 4.28 1.54 0.219 0.021
Depression 3.51 0.47 2.17 1.14 1.19 0.279 0.017
Anxiety 3.28 0.42 1.83 1.02 1.71 0.196 0.023
Stress 5.73 0.51 3.66 1.22 2.44 0.123 0.033
Insomnia 9.21 0.73 8.23 1.75 0.267 0.607 0.004
Negative Aect 17.67 0.88 16.62 2.11 0.211 0.647 0.003
aAdjusted means aer controlling for endpoint scores are presented.
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Frontiers in Psychology 10 frontiersin.org
baseline to endpoint. Finally, insomnia symptom scores decreased
by 36% and negative aect by 16% from baseline to endpoint. e
degree to which each of these domains changed from baseline to
endpoint is demonstrated by paired sample comparisons in Table3.
Long term 18 months follow-up outcomes
e observed increase in growth domains and decrease in
symptomatology domains across participants immediately
following the Warrior PATHH program sheds light on just how
powerful an intensive training of this type can be. However, it is
important to examine whether the improvements are maintained
long-term aer the individuals return to their normal environment.
For example, each individual who attends the training has removed
themselves from many of the daily stressors they experience, is
given a strict schedule to adhere to, and is surrounded by
individuals with similar experiences who are more likely to
understand their struggles. Once the individual returns home, they
are again exposed to any routine daily stressors, are responsible for
their own schedule, and may not have the same level of empathetic
community found during training. Signicant results at the
18 months follow-up would indicate a high level of impact from the
training, resulting in changes that are maintained for one and a half
years post-training.
Data from repeated measures ANOVAs indicates that, for those
who provided data at all three time points (n = 74), the signicant
increase in all growth-related outcome measure scores from
baseline was maintained at the 18 months follow-up. Both PTGI-X
and ISLES scores did not dier signicantly from endpoint to
follow-up, indicating stability and lasting benets from the training
program. Although there was a signicant decrease in positive
aect scores between endpoint and follow-up assessments, the
scores remained signicantly higher than baseline, indicating a
lasting positive impact of the training.
Scores on all symptomatology-related outcome measures that
exhibited a signicant decrease from baseline to endpoint
remained stable at the 18 months follow-up, maintaining their
signicant decrease from the baseline assessment. While both
anxiety and negative aect scores experienced a non-signicant
decrease from baseline to endpoint, scores for both domains
experienced a signicant decrease from baseline to
follow-up assessment.
Examination of gender of participants
e present study also aimed to investigate the potential
dierences between male and female participants on various growth
and symptomatology-related outcome measures at both endpoint and
follow-up. e results of multiple one-way ANCOVA’s indicate that
aer adjusting for pre-intervention scores, there was only a single
outcome measure, DASS anxiety subscale scores, that showed a small
but statistically signicant dierence in post-intervention scores
between male and female participants. e eect size, as indicated by
the partial η
2
value, was very small, only explaining approximately
2.3% of the variance in scores on the anxiety subscale.
Interestingly, no signicant gender dierences were found for any
other growth or symptomatology related outcome measure at
endpoint or follow-up, aer controlling for the appropriate covariates.
ese ndings indicate that on almost all outcome variables assessed,
male and female participants showed similar levels of improvement at
endpoint and maintenance of such improvement at follow-up.
e discrepancy in samples size for the analyses examining gender
dierences at follow-up should benoted, as male participants (n = 63)
far outnumbered female participants (n = 11). is overall small
sample of participants may have inuenced the statistical power to
detect dierences between genders. Furthermore, the smaller sample
size of female participants may have limited the ability to detect any
eects that could have been present.
e ndings of these analyses are encouraging in that both female
and male veterans seem to experience the same level of benet from
the posttraumatic growth-oriented training employed in this study.
More specically, the large increases in PTG and decreases in PTSD
symptomatology were exhibited by participants, regardless of gender.
ese results indicate that the current training protocol seems to
adequately address the needs of both male and female veterans,
however future studies with larger and more balanced gender samples
are needed to further explore the potential inuence of gender on the
assessed variables.
PCL-5 threshold scores
e PCL-5 was used to assess prevalence and severity of PTSD
symptomatology among participants completing the training
program. e high impact of the training on post-intervention and
long-term follow up PCL-5 scores warrants further investigation.
While the use of the PCL-5 was strictly to assess prevalence and
severity of PTSD symptoms, and not a tool used to make a diagnosis,
an investigation of the participants who fall above and below the
diagnosis threshold score can be informative. For example, a
provisional PTSD diagnosis can bemade with a score of 33 or greater
on the PCL-5. At the baseline assessment (n = 184), there were 120
individuals with scores greater than 33 and who theoretically would
qualify for this provisional diagnosis. Immediately following the
training, only 31 individuals had scores greater than 33, indicating
that 89 individuals (74%) have theoretically reduced symptomatology
to a point that would no longer meets the diagnostic threshold. For
those who provided data at all three study time points (n = 74), there
were 40 individuals with PCL-5 scores greater than 33, meeting
criteria for a provisional PTSD diagnosis at the baseline assessment.
At the endpoint assessment, only 12 individuals had scores greater
than 33, indicating 28 fewer individuals (70%) met the diagnostic
criteria regarding PCL-5 scores. One and a half years later at the
18 months follow-up assessment, 15 individuals had PCL5 scores
greater than 33 indicating a rise in PTSD symptoms over the course
of 18 months for 3 of the individuals. is rise in the number of
individuals who exceed the diagnostic threshold is expected over
time but highlights the need for continued support beyond the
immediate post-intervention period.
Together, these results underscore the positive impact of the
Warrior PATHH training program in reducing PTSD symptomatology
among veterans, despite its primary focus of increasing PTG. e
substantial impact on reported PTSD symptomatology, exhibited by
a 49% decrease in reported symptoms from baseline to endpoint,
warrants further investigation to identify factors associated with
increased PTG and symptom improvement.
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Frontiers in Psychology 11 frontiersin.org
Limitations
e present study is not without its limitations, primarily the lack
of a control group. While a single-group design is appropriate for the
current study, future studies should consider employing randomized
controlled trail designs to further investigate the eects of the training
and help establish causal relationships. e ethics and complexity of
adding a control group to a study of this nature should becarefully
examined to account for many of the factors present in the current
training protocol.
While demographic variables were collected, certain variables that
may beof interest to the eld were not collected in this study (i.e.,
nature of trauma, time since trauma, and age of service). Analysis of
the relationship between these and outcome variables may identify
certain patterns in training benet.
Finally, the findings of this study were based on a specific
manualized intervention within a specific population, U.S. military
veterans. While the sample size and analyses allow for the results
to begeneralizable to U.S. military veteran populations, they may
not begeneralizable to other study populations. Future studies
should consider adapting and employing the utilized training
among other populations that are at an increased risk of
trauma exposure.
Conclusion
In conclusion, the results of this study demonstrated signicant
improvements in growth-related outcomes, including posttraumatic
growth, positive aect, and the integration of stressful life experiences,
immediately following the training. ese improvements were
generally maintained until the follow-up assessment, 18 months later,
indicating the potential for enduring positive eects. Additionally,
participants showed signicant reduction in symptoms related to
PTSD, depression, anxiety, stress, insomnia, and negative aect. ese
reductions in symptom-related measures were also maintained until
the follow-up assessment. Together, the evidence indicates that the
employed posttraumatic growth-oriented training program provides
benets to veterans extending beyond increases in posttraumatic
growth, addressing many of the issues that veterans face following
exposure to trauma.
An important implication of the impact of this training program
involves the use of peer-based delivery. e substantial impact of this
peer-based approach suggests that a properly designed program
delivered by peers who have a high degree of cultural competence may
provide a unique pathway to addressing mental health needs. ere is
also the implication that peers may beespecially eective at delivering
such programs as they optimize the important relational component
that is central to success.
Data availability statement
e datasets presented in this article are not readily available because
of concerns for condentiality. Requests to access the datasets should be
directed to the corresponding author, GE, gary_elkins@baylor.edu.
Ethics statement
e studies involving humans were approved by Baylor
University’s Institutional Review Board. e studies were conducted
in accordance with the local legislation and institutional requirements.
e participants provided their written informed consent to
participate in this study.
Author contributions
JR: Conceptualization, Data curation, Formal analysis, Investigation,
Methodology, Writing – original dra, Writing – review & editing. RT:
Conceptualization, Data curation, Investigation, Methodology, Project
administration, Supervision, Writing – review & editing. BM:
Conceptualization, Data curation, Investigation, Methodology, Project
administration, Supervision, Writing – review & editing. CA:
Conceptualization, Writing – review & editing. GE: Conceptualization,
Data curation, Formal analysis, Investigation, Methodology, Supervision,
Writing – original dra, Writing – review & editing.
Funding
e author(s) declare that no nancial support was received for
the research, authorship, and/or publication of this article.
Conflict of interest
RT, BM, and GE receive payment for consulting services through
the Boulder Crest Institute for Posttraumatic Growth.
e remaining authors declare that the research was conducted in
the absence of any commercial or nancial relationships that could
beconstrued as a potential conict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their aliated organizations,
or those of the publisher, the editors and the reviewers. Any product
that may be evaluated in this article, or claim that may be made by its
manufacturer, is not guaranteed or endorsed by the publisher.
References
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., and Swinson, R. P. (1998).
Psychometric properties of the 42-item and 21-item versions of the depression anxiety
stress scales in clinical groups and a community sample. Psychol. Assess. 10, 176–181.
doi: 10.1037/1040-3590.10.2.176
Asmundson, G. J. G., orisdottir, A. S., Roden-Foreman, J. W., Baird, S. O., and
Witcra, S. M. (2019). A meta-analytic review of cognitive processing therapy for adults
with posttraumatic stress disorder. Cogn. Behav. er. 48, 1–14. doi:
10.1080/16506073.2018.1522371
Barlow, D. H. (2014). Clinical handbook of psychological disorders: a step-by-step
treatment manual, 5th (D. H. Barlow, Ed.). New York, NY: e Guilford Press. Available
at: http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2014-05860-00
0&authtype=shib&site=ehost-live&scope=site
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 12 frontiersin.org
Bastien, C. H., Valliéres, A., and Morin, C. M. (2001). Validation of the insomnia
severity index as an outcome measure for insomnia research. Sleep Med. 2, 297–307. doi:
10.1016/S1389-9457(00)00065-4
Bovin, M. J., Marx, B. P., and Schnurr, P. P. (2015). Evolving DSM diagnostic criteria
for PTSD: relevance for assessment and treatment. Curr Treatm Opt Psychiatr 2, 86–98.
doi: 10.1007/s40501-015-0032-y
Brown, T. A., Chorpita, B. F., Korotisch, W., and Barlow, D. H. (1997). Psychometric
properties of the depression anxiety and stress scales (DASS) in clinical samples. Beh av.
Res. er. 35, 79–89. doi: 10.1016/S0005-7967(96)00068-X
Brunet, J., McDonough, M. H., Hadd, V., Crocker, P. R.El, and Sabiston, C. M. (2010).
e posttraumatic growth inventory: an examination of the factor structure and invariance
among breast cancer surviors. Psycho-Oncology, 19, 830–838. doi: 10.1002/pon.1640
Calhoun, L., and Tedeschi, R. (2013). Posttraumatic growth in clinical practice. New
York: Routledge
Chard, K. M., Schumm, J. A., Owens, G. P., and Cottingham, S. M. (2010). A
comparison of OEF and OIF veterans and Vietnam veterans receiving cognitive
processing therapy. J. Trauma. Stress. 23:20500. doi: 10.1002/jts.20500
Chen, Y.-R., Hung, K.-W., Tsai, J.-C., Chu, H., Chung, M.-H., and Chen, S.-R. (2014).
Ecacy of eye-movement desensitization and reprocessing for patients with
posttraumatic-stress disorder: a meta-analysis of randomized controlled trials. PLoS One
9:e103676. doi: 10.1371/journal.pone.0103676
Cooper, M., Norcross, J. C., Raymond-Barker, B., and Hogan, T. P. (2019).
Psychotherapy preferences of laypersons and mental health professionals: whose therapy
is it? Psychotherapy 56, 205–216. doi: 10.1037/pst0000226
Crawford, J. R., and Henry, J. (2004). e positive and negative aect schedule
(PANAS): construct validity, measurement properties and normative data in a large
non-clinical sample. Br. J. Clin. Psychol. 43, 245–265. doi: 10.1348/0144665031752934
Department of Veterans Aairs, & Department of Defense. (2017). VA/D OD clinical
practice guideline for the management of posttraumatic stress disorder and acute stress
disorder – Version 3.0. Available at: https://www.healthquality.va.gov/guidelines/MH/
ptsd/VADoDPTSDCPGFinal012418.pdf
Dutra, S. J., Hayes, J. P., and Keane, T. M. (2019). Issues in assessment of PTSD in
military personnel. B. A. Moore and W. E. Penk (Eds.), Treating PTSD in military
personnel: A clinical handbook 2nd, 22–45). e Guilford Press
Eekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., and
Karlin, B. E. (2013). Eectiveness of national implementation of prolonged exposure
therapy in veterans aairs care. JAMA Psychiatry 70, 949–955. doi: 10.1001/
jamapsychiatry.2013.36
Foa, E. B., Hembree, E. A., Cahill, S. P., Rauch, S. A. M., and Riggs, D. S. (2005).
Randomized trial of prolonged exposure for posttraumatic stress disorder with and
without cognitive restructuring: outcome at academic and community clinics. J. Consult.
Clin. Psychol. 73, 953–964. doi: 10.1037/0022-006X.73.5.953
Foa, E. B., McLean, C. P., Zang, Y., Roseneld, D., Yadin, E., and Yarvis, J. S. (2018).
Eect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-
centered therapy on PTSD symptom severity in military personnel. JAMA 319, 354–364.
doi: 10.1001/jama.2017.21242
Frankl, V. E. (1962). Man’s search for meaning: an introduction to Logotherapy Beacon Press.
Gloster, A. T., R hoades, H. M., Novy, D., Klotsche, J., Senior, A., and Kunik, M. (2008).
Psychometric properties of the depression anxiety and stress scale-21in older primary
care patients. J Aect Disord, 110, 248–259. doi: 10.1016/j.jad.2008.01.023
Haskell, S. G., Gordon, K. S., Mattocks, K., Duggal, M., Erdos, J., and Justice, A. (2010).
Gender dierences in rates of depression, PTSD, pain, obesity, and military sexual
trauma among Connecticut war veterans of Iraq and Afghanistan. J Womens Health
(Larchmt) 19, 267–271. doi: 10.1089/jwh.2008.1262
Hendriks, L., de Kleine, R. A., Broekman, T. G., Hendriks, G.-J., and van Minnen, A.
(2018). Intensive prolonged exposure therapy for chronic PTSD patients following
multiple trauma and multiple treatment attempts. Eur. J. Psychotraumatol. 9:1425574.
doi: 10.1080/20008198.2018.1425574
Hijazi, A. M., Lumley, M. A., Ziadni, M. S., Haddad, L., and Rapport, L. J. (2014).
Brief narrative exposure therapy for posttraumatic stress in Iraqi refugees: a
preliminary randomized clinical trial. J. Trauma. Stress. 27, 314–322. doi: 10.1002/
jts.21922
Holland, J. M., Currier, J. M., Coleman, R. A., and Neimeyer, R. A. (2010). e
integration of stressful life experiences scale (ISLES): development and initial validation
of a new measure. Int. J. Stress. Manag. 17, 325–352. doi: 10.1037/a0020892
Hoskins, M., Pearce, J., Bethell, A., Dankova, L., Barbui, C., and Tol, W. A. (2015).
Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-
analysis. Br. J. Psychiatry 206, 93–100. doi: 10.1192/bjp.bp.114.148551
Jano-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events:
applications of the schema construct. Soc. Cogn. 7, 113–136. doi: 10.1521/
soco.1989.7.2.113
Jano-Bulman, R. (2006). Schema-change perspectives on posttraumatic growth. L.
G. Calhoun and R. G. Tedeschi (Eds.), Handbook of posttraumatic growth: research &
practice, 81–99. Mahwah, NJ: Lawrence Erlbaum Associates Publishers
Kehle-Forbes, S. M., Meis, L. A., Spoont, M. R., and Polunsy, M. A. (2016). Initiation
and dropout from prolonged exposure and cognitive reprocessing therapy in a VA
outpatient clinic. Psychol. Trauma eory Res. Pract. Policy 8, 107–114. doi: 10.1037/
tra0000065
Kimerling, R., Street, A. E., Pavao, J., Smith, M. W., and Cronkite, R. C. (2010).
Military-related sexual trauma among veterans health administration patients returning
from Afghanistan and Iraq. Am. J. Public Health 100, 1409–1412. doi: 10.2105/
AJPH.2009.171793
Lee, J. A., Luxton, D. D., Reger, G. M., and Gahm, G. A. (2010). Conrmatory factor
analysis of the posttraumatic growth inventory with a sample of soldiers previously
deployed in support of the Iraq and Afghanistan wars. J. Clin. Psychol. 66, 813–819. doi:
10.1002/jclp.20692
Linley, P. A., Andrws, L., and Joseph, S. (2007). Conrmatory factor analysis of the
posttraumatic growth inventory. J. Loss Trauma 12, 321–332. doi:
10.1080/15325020601162823
Liu, Y., Collins, C., Wang, K., Xie, X., and Bie, R. (2019). e prevalence and trend of
depression among veterans in the UnitedStates. J. Aect. Disord. 245, 724–727. doi:
10.1016/j.jad.2018.11.031
Macera, C. A., Aralis, H. J., Highll-McRoy, R ., and Rauh, M. J. (2014). Posttraumatic
stress disorder aer combat zone deployment among navy and marine corps men and
women. J Womens Health (Larchmt) 23, 499–505. doi: 10.1089/jwh.2013.4302
McKinney, J. M., Hirsch, J. K., and Britton, P. C. (2017). PTSD symptoms and suicide
risk in veterans: serial indirect eects via depression and anger. J. Aect. Disord. 214,
100–107. doi: 10.1016/j.jad.2017.03.008
McLean, C. P., Levy, H. C., Miller, M. L., and Tolin, D. F. (2022). Exposure therapy for
PTSD: a meta-analysis. Clin. Psychol. Rev. 91:102115. doi: 10.1016/j.cpr.2021.102115
Meichenbaum, D. (2012). Roadmap to resilience: a guide for military, trauma victims
and their families. Waterloo, ON: Institute Press
Moore, B. A., Tedeschi, R. G., and Greene, T. C. (2021). A preliminary examination of
a posttraumatic growth-based program for veteran mental health. Pract. Innov. 6, 42–54.
doi: 10.1037/pri0000136
Morin, C. M., Belleville, G., Belanger, L., and Ivers, H. (2011). e insomnia severity
index: psychometric indicators to detect insomnia cases and evaluate treatment
response. Sleep 34, 601–608. doi: 10.1093/sleep/34.5.601
Neimeyer, R. A. (2006). Re-storying loss: fostering growth in the posttraumatic
narrative. L. G. Calhoun and R. G. Tedeschi (Eds.), Handbook of posttraumatic growth:
Research & practice. (68–80). Mahwah, NJ: Lawrence Erlbaum Associates Publishers
Norcross, J. C., and Wampold, B. E. (2011). Evidence-based therapy relationships:
research conclusions and clinical practices. Psychotherapy 48, 98–102. doi: 10.1037/
a0022161
Peterson, A. L., Foa, E. B., and Riggs, D. S. (2019). Prolonged exposure therapy. B. A.
Moore and W. E. Penk (Eds.), Treating PTSD in military personnel: A clinical handbook
(46–62). Guilford Press
Polusny, M. A., Kumpula, M. J., Meis, L. A., Erbes, C. R., Arbisi, P. A., and Murdoch, M.
(2014). Gender dierences in the eects of deployment-related stressors and pre-
deployment risk factors on the development of PTSD symptoms in National Guard
Soldiers deployed to Iraq and Afghanistan. J. Psychiatr. Res. 49, 1–9. doi: 10.1016/j.
jpsychires.2013.09.016
Resick, P. A., Monson, C. M., and Chard, K. M. (2008). Cognitive processing therapy:
veteran/military version. Washington, DC: Department of Veterans Aairs
Resick, P. A., Nishith, P., Weaver, T. L., Astin, M. C., and Feuer, C. A. (2002). A
comparison of cognitive-processing therapy with prolonged exposure and a waiting
condition for the treatment of chronic posttraumatic stress disorder in female rape
victims. J. Consult. Clin. Psychol. 70, 867–879. doi: 10.1037//0022-006x.70.4.867
Roepke, A. M., and Seligman, M. E. P. (2015). Doors opening: a mechanism for growth
aer adversity. J. Posit. Psychol. 10, 107–115. doi: 10.1080/17439760.2014.913669
Rothbaum, B. O., Astin, M. C., and Marsteller, F. (2005). Prolonged exposure versus
eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. J.
Trauma. Stress. 18, 607–616. doi: 10.1002/jts.20069
Russell, P. D., Judkins, J. L., Blessing, A., Moore, B., and Morissette, S. B. (2022).
Incidences of anxiety disorders among active duty service members between 1999 and
2018. J. Anxiety Disord. 91:102608. doi: 10.1016/j.janxdis.2022.102608
Schultz, J. M., Tallman, B. A., and Altmaier, E. M. (2010). Pathways to posttraumatic
growth: the contributions of forgiveness and importance of religion and spirituality.
Psychol. Relig. Spiritual. 2, 104–114. doi: 10.1037/a0018454
Shapiro, F. (1989). Eye movement desensitization: a new treatment for post-traumatic
stress disorder. J. Behav. er. Exp. Psychiatry 20, 211–217. doi:
10.1016/0005-7916(89)90025-6
Shakespeare-Finch, J., Martinek, E., Tedeschi, R. G., and Calhoun, L. G. (2013). A
qualitative approach to assessing the validity of the posttraumatic growth inventory.
J Loss Trauma. 18:572–591. doi: 10.1080/15325024.2012.734207
Smith, N. B., Sippel, L. M., Rozek, D. C., Ho, R. A., and Harpaz-Rotem, I. (2019).
Predictors of dropout from residential treatment for posttraumatic stress disorder
among military veterans. Front. Psychol. 10:362. doi: 10.3389/fpsyg.2019.00362
Rhodes et al. 10.3389/fpsyg.2023.1322837
Frontiers in Psychology 13 frontiersin.org
Smyth, J. M., Hockemeyer, J. R., and Tulloch, H. (2008). Expressive writing and post-
traumatic stress disorder: eects on trauma symptoms, mood states, and cortisol
reactivity. Br. J. Health Psychol. 13, 85–93. doi: 10.1348/135910707X250866
Steenkamp, M. M., Litz, B. T., Hoge, C. W., and Marmar, C. R. (2015). Psychotherapy
for military-related PTSD: a review of randomized clinical trials. JAMA 314, 489–500.
doi: 10.1001/jama.2015.8370
Steenkamp, M. M., Litz, B. T., and Marmar, C. R. (2020). First-line psychotherapies
for military-related PTSD. JAMA 323, 656–657. doi: 10.1001/jama.2019.20825
Taku, K., Cann, A., Calhoun, L. G., and Tedeschi, R. G. (2008). e factor structure of
the posttraumatic growth inventory: a comparison of ve models using conrmatory
factor analysis. J. Trauma. Stress. 21, 158–164. doi: 10.1002/jts.20305
Tedeschi, R., Cann, A., Taku, K., Senol-Durak, E., and Calhoun, L. G. (2017). e
posttraumatic growth inventory: a revision integrating existential and spiritual change.
J. Trauma. Stress. 30, 11–18. doi: 10.1002/jts.22155
Tedeschi, R. G., and Calhoun, L. G. (1996). e posttraumatic growth inventory:
measuring the positive legacy of trauma. J. Trauma. Stress. 9, 455–471. doi: 10.1207/
BF02103658
Tedeschi, R. G., and Calhoun, L. G. (2006). Expert companions: posttraumatic growth
in clinical practice. L. G. Calhoun and R. G. Tedeschi (Eds.), Handbook of posttraumatic
growth: research & practice. (291–310). Mahwah, NJ:
Lawrence Erlbaum Associates Publishers
Tedeschi, R. G., and McNally, R. J. (2011). Can wefacilitate posttraumatic growth in
combat veterans? Am. Psychol. 66, 19–24. doi: 10.1037/a0021896
Tedeschi, R. G., and Moore, B. A. (2018). Boulder crest retreat: integrating non-
traditional and traditional interventions for military veterans. Mil. Psychol. 33, 11–14.
Tedeschi, R. G., and Moore, B. A. (2021). Posttraumatic growth as an integrative
therapeutic philosophy. J. Psychother. Integr. 31, 180–194. doi: 10.1037/int0000250
Tedeschi, R. G., and Rie, O. M. (2016). Posttraumatic growth and logotherapy:
nding meaning in trauma. Int. Forum Logoth. 39, 40–47.
Tedeschi, R. G., Shakespeare-Finch, J., Taku, K., and Calhoun, L. G. (2018).
Posttraumatic growth: eory, research, and practice. New York: Routledge
Tedeschi, R., and Moore, B. A. (2016). e posttraumatic growth workbook: Coming
through trauma wiser, stronger, and more resilient. Oakland, CA: New Harbinger
U.S. Department of Veterans Aairs. (2021). 2021 National Veteran Suicide Prevention:
Annual report. Washington, DC
Valiente-Gómez, A., Moreno-Alcázar, A., Treen, D., Cedrón, C., Colom, F., and
Pérez, V. (2017). EMDR beyond PTSD: A Systematic Literature Review. Frontiers in
Psychology, 8, 1668. doi: 10.3389/fpsyg.2017.01668
Watkins, L. E., Sprang, K. R., and Rothbaum, B. O. (2018). Treating PTSD: a review of
evidence-based psychotherapy interventions. Front. Behav. Neurosci. 12:258. doi:
10.3389/fnbeh.2018.00258
Watson, D., Clark, L. A., and Tellegen, A. (1988). Development and validation of brief
measures of positive and negative aect: the PANAS scales. J. Pers. Soc. Psychol. 54,
1063–1070. doi: 10.1037/0022-3514.54.6.1063
Weathers, F. W., Blake, D. D., Scnurr, P. P., Kaloupek, D. G., Marx, B. P., and
Keane, T. M. (2013). e clinician-administered PTSD scale for DSM-5 (CAPS-5).
National Center for PTSD, Available at: www.ptsd.va.gov
Williams, A. H., Galovski, T. E., and Resick, P. A. (2019). C ognitive processing therapy.
B. A. Moore and W. E. Penk (Eds.), Treating PTSD in military personnel: a clinical
handbook (63–77). Guilford Press
Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., and Southwick, S. M. (2014).
Posttraumatic stress disorder in the US veteran population: results from the National
Health and resilience in veterans study. J. Clin. Psychiatry 75, 1338–1346. doi: 10.4088/
JCP.14m09328
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