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. Author manuscript; available in PMC: 2024 Jun 1.
Published in final edited form as: J Trauma Stress. 2023 Feb 2;36(3):537–548. doi: 10.1002/jts.22908

Social support and treatment utilization for posttraumatic stress disorder: Examining reciprocal relations among active duty service members

Anna E Jaffe 1, Thomas O Walton 2, Denise D Walker 2, Debra L Kaysen 3,4
PMCID: PMC10293030  NIHMSID: NIHMS1875003  PMID: 36728194

Abstract

Evidence-based treatments for posttraumatic stress disorder (PTSD) are underutilized by active duty service members in the United States. Social support may help service members overcome avoidance and facilitate treatment utilization. In turn, treatment utilization may improve social support. To evaluate these possibilities, the aim of the current study was to examine potential reciprocal associations between social support and treatment utilization among service members. Secondary analyses were conducted on a randomized controlled trial of 161 U.S. military service members with PTSD. Participants completed assessments of perceived social support and attendance at individual therapy sessions at baseline and 3- and 6-month follow-ups. To determine reciprocal relations between social support and treatment utilization, a Bayesian approach was used to estimate a random-intercept cross-lagged panel model with a two-part variable for treatment utilization (i.e., any therapy, and if so, dose). There were no between-person associations between average social support and treatment utilization. One prospective cross-lagged within-person association emerged as significant: social support at 3 months was negatively associated with any therapy use at 6 months; the model explained 26.1% of the variance in this observed variable. The findings revealed that low social support promoted subsequent treatment utilization, but such treatment did not lead to changes in social support. This suggests service members with PTSD may have been motivated to attend individual therapy in pursuit of social connection and support. Future research is needed to determine if reciprocal associations between various forms of social support and therapy utilization differ by treatment modality.

Service members of the U.S. military are at heightened risk for posttraumatic stress disorder (PTSD) following exposure to potentially traumatic events both in the military and earlier in life (Cabrera et al., 2007). Although 5%–20% of service members meet the criteria for PTSD (Ramchand et al., 2010) and, therefore, may benefit from efficacious therapies for treating PTSD (e.g., cognitive processing therapy, prolonged exposure; Department of Veterans Affairs [VA] & Department of Defense [DoD], 2017), psychotherapy remains underutilized among this population. Despite efforts by the military health system to train clinicians in empirically supported therapies for PTSD (Hepner et al., 2018), a recent review demonstrated that less than one third of service members with a past-year mental health problem had sought mental health services during that time period, a rate lower than in civilian samples (Hom et al., 2017). Barriers to care among military populations are numerous and can include concern about harm to one’s military career, perceived stigma, structural barriers to obtaining and keeping appointments with providers, and mistrust of providers or treatments (see Coleman et al., 2017; Hom et al., 2017; Johnson & Possemato, 2019). Thus, there is a need to understand mechanisms for overcoming such barriers and facilitating PTSD treatment utilization among service members.

Social support, which typically refers to the provision of emotional, informational, or instrumental (i.e., practical) assistance by influential or important people in one’s life (Thoits, 2011), has emerged as one such potential facilitator of PTSD treatment utilization. Although the link between higher social support and lower levels of PTSD symptom severity has been well-established within military populations (Blais et al., 2021), the underlying mechanisms and directionality of this association are uncertain. One possibility is that higher levels of social support buffer the effects of trauma, protecting against PTSD (i.e., the social causation model; Johnson et al., 1999; Kaniasty & Norris, 2008). Another possibility is that individuals who develop more severe symptoms of PTSD may experience increasing isolation, the erosion of social structures, and a degradation of social support over time (i.e., the social selection model; Johnson et al., 1999; Kaniasty & Norris, 1993, 2008). Comparing these possibilities, a recent meta-analysis revealed comparable support for both social causation and social selection (Wang et al., 2021), indicating that social support and PTSD are reciprocally related over time.

When PTSD does develop, social support may facilitate treatment utilization. The health belief model (Carpenter, 2010; Rosenstock, 1966) proposes that a person will be motivated to engage in a target health-promoting behavior, such as PTSD treatment, if they view themselves as being susceptible to a negative health outcome, believe the target behavior will prevent or mitigate that outcome, and perceive few barriers to the target behavior. Social factors can affect each aspect of this process as applied to seeking treatment for PTSD. First, the process of recognizing and labeling PTSD symptoms as a problem that merits intervention often occurs in social contexts. For example, Spoont et al. (2009) found that when veterans were asked what led them to believe they had PTSD, they often reported receiving social feedback on the distress they experienced. This feedback could include unsolicited comments about changes in their mood or functioning, validation of an expression of distress, or social comparison between others’ behavior and their own. Second, the belief that PTSD treatment could effectively reduce distress might be affected by social norms and conversations with trusted others about their treatment experiences (Hipes, 2011). Third, social support can help individuals overcome barriers to treatment. One such barrier is an individual’s belief that they should be able to handle problems without help (Bogaers, 2022). Among veterans, higher perceived social support has been associated with a lower likelihood of endorsing this belief and, in turn, more treatment utilization when controlling for PTSD severity (Graziano & Elbogen, 2017). Another common barrier to PTSD treatment is a desire to avoid talking or thinking about traumatic events (Kantor et al., 2017). Social supporters may help individuals overcome such avoidance. Indeed, having friends and family provide support for PTSD treatment has been associated with increased treatment utilization (Spoont et al., 2014; Zinzow et al., 2015), in part because such support promotes better attitudes toward treatment (Black et al., 2019). In these ways, social support may facilitate treatment utilization.

On the other hand, it is also possible that utilizing treatment for PTSD may facilitate more social support. A review of randomized clinical trials of psychotherapy for military-related PTSD found that evidence-based PTSD treatments lead to diagnostic remission in fewer than half of patients (28%–40%), but most patients (49%–70%) do achieve significant reductions in PTSD symptom severity (Steenkamp et al., 2015). Further, more consistent therapy utilization may signal a stronger therapeutic alliance (Sijercic et al., 2021), which has, in turn, been associated with better PTSD treatment outcomes (Howard et al., 2022). Given that more severe PTSD symptoms can erode social support over time (Wang et al., 2021), treatment-related reductions in PTSD may alleviate distress and associated isolation, allowing for improved social support. Additionally, some evidence-based strategies for PTSD specifically promote interpersonal interactions. For example, in a sample of veterans with PTSD, behavioral activation was associated with a larger posttreatment increase in the number of social supports than treatment as usual (Campbell et al., 2019). Case studies have also suggested that Skills Training in Affective and Interpersonal Regulation (STAIR; Cloitre et al., 2002, 2020) may be useful to promote social engagement among veterans who have experienced military sexual trauma (Cloitre et al., 2016). However, it is unknown whether engaging in standard psychotherapy for PTSD, outside of a clinical trial, is associated with subsequent changes in social support.

Despite this conceptual support for a reciprocal positive association between perceived social support and treatment utilization, prior research in military samples has yielded mixed results, suggesting the need for more research. Some empirical research (e.g., Spoont et al., 2014; Zinzow et al., 2015) has supported a positive association, and in interviews, active duty service members have identified social support as a primary facilitator of treatment seeking (Bogaers et al., 2020; Zinzow et al., 2013). Another study found that more social support was specifically associated with utilization of pharmacotherapy, but not psychotherapy (Kehle et al., 2010). Still others have reported no association (Sripada et al., 2015) or a negative association (DeViva et al., 2016) between social support and treatment utilization. For example, among 66 veterans with PTSD symptoms in VA mental health treatment, higher postdeployment social support was found to be associated with attending fewer sessions (DeViva et al., 2016). However, higher social support may have been an indicator of less severe psychopathology in this sample, as less severe PTSD was also associated with attending fewer mental health care sessions. Given the robust association between social support and PTSD (Wang et al., 2021), it is important to determine the link between social support and treatment utilization when holding PTSD severity constant.

In sum, social support may be an important facilitator of PTSD treatment-seeking and utilization (Bogaers et al., 2020; Zinzow et al., 2013), and psychotherapies for PTSD may, in turn, facilitate higher perceived social support (Campbell et al., 2019; Cloitre et al., 2016). However, a thorough understanding of how these potentially reciprocal relations unfold over time is lacking. Prior research has been limited by a focus on cross-sectional designs (see Spoont et al., 2014, for an exception), inconsistent operationalizations of treatment utilization (e.g., any contact, completing a course of psychotherapy; Hom et al., 2017), and not controlling for PTSD symptoms when examining the role of associated social support (e.g., DeViva et al., 2016). Thus, the aim of the current longitudinal study was to examine potential reciprocal relations between social support and treatment utilization among service members. Associations were examined over 6 months in the context of a randomized controlled trial (RCT) for active duty service members with PTSD. Consistent with best practices for the analysis of longitudinal data (e.g., Hamaker et al., 2015), we disaggregated between-person differences from within-person associations. Regarding between-person associations, we anticipated that higher average levels of social support across the study would be associated with more consistent treatment utilization across the study period, after controlling for baseline PTSD symptom severity, recruitment source, sex assigned at birth, and randomly assigned intervention condition. When accounting for these between-person differences, we expected there would be within-person associations such that elevated social support would be associated with more subsequent treatment utilization and, in turn, more treatment utilization would be associated with higher subsequent social support.

METHOD

Participants

Inclusion criteria

Individuals were eligible to participate if they (a) were active duty, reserve, or National Guard U.S. military personnel; (b) met the criteria for PTSD per the Diagnostic and Statistical Manual for Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013); and (c) were not engaged in evidence-based PTSD treatment at the time of enrollment, defined as either receiving a recommended medication for PTSD (VA/DoD, 2017) or meeting with an individual therapist at least every 2 weeks and focusing on PTSD symptoms and/or the traumatic event itself in every session. Individuals were excluded if they screened positive for possible psychosis, were not fluent in English, or anticipated a deployment that would preclude intervention and assessment completion.

Recruitment

Participants were recruited from two sources: nationally through an online recruitment campaign, with ads placed on popular social network sites, and locally via printed materials (e.g., posters, flyers, brochures) placed throughout a large U.S. military base in the Pacific Northwest. Ads targeted service members who had questions or concerns about PTSD symptoms and clarified the confidential nature of participation.

Sample description

Of the 471 service members screened for eligibility, 161 were eligible and enrolled in the trial. On average, participants were 29.7 years old (SD = 7.5, range: 19–54). Most participants (68.3%) were cisgender men; 29.8% were cisgender women, 1.2% were transgender/nonbinary and assigned female sex at birth; and one participant (0.6%) declined to state their gender or sex. Regarding sexual identity, 82.6% were heterosexual, 11.2% were bisexual, and 5.6% were gay or lesbian; 0.6% declined to state. The sample was 74.5% White/Caucasian, 6.8% Black/African American, 1.9% American Indian/Alaskan Native, 1.9% Asian/Asian American, 0.6% Native Hawaiian/Pacific Islander, 4.3% other; 6.8% reported multiple racial identities, and 3.1% declined to state. In addition, 13.0% of participants were Hispanic or Latino/a. Soldiers were most prevalent in the sample (80.1%), followed by airmen (16.1%) and sailors (3.7%). The sample was 69.6% active duty, 19.3% National Guard, and 11.2% reservists. Most served in an enlisted paygrade (43.5% E1–E4, 43.5% E5–E9, 11.2% O1–O9, 1.9% W1–W5). The average service tenure was 8.9 years (SD = 6.3, range: 1–27), and 56.3% of the sample had been deployed to a combat zone at least once.

Procedure

Data for the present secondary analysis were collected within an RCT testing a novel motivational enhancement therapy (MET) designed to support treatment engagement among military personnel with untreated PTSD. Data were collected between January 2018 and September 2021. For a full description of the parent trial, see Kaysen et al. (2022). All participants provided informed consent prior to enrollment. All procedures involving human subjects were approved by the University of Washington Institutional Review Board with additional oversight provided by the Department of Defense Human Research Protections Office.

Upon enrollment, participants were randomly assigned to either the experimental MET intervention or a treatment-as-usual (TAU) comparison condition. Four blocking variables were employed in randomization: gender, recruitment source (local vs. national), service branch, and PTSD symptom severity. The novel MET intervention includes an initial session (45–90 min) followed by two optional follow-up sessions (30–60 min each), which were completed within 4–6 weeks following enrollment. Sessions were conducted over the phone by psychotherapists who employed motivational interviewing techniques (Miller & Rollnick, 2013), a personalized feedback report, and a referral booklet to support participants in exploring their ambivalence about taking steps to address PTSD. Participants assigned to TAU were mailed the same referral booklet but received no further clinical contact. They were, however, given the option of receiving the MET intervention following the completion of the trial. For more details about the interventions and their efficacy, see Walker et al. (2022).

Measures

Participants completed screening and baseline assessments within 10 days and follow-ups at 6 weeks, 3 months, and 6 months after baseline. Study assessors, who were trained at the master’s level in a therapeutic discipline, administered all assessments by phone; participants could choose to complete the 6-week assessment online. Participants received the following compensation for completing assessments: $25 (USD) for baseline (60–75 min), $25 for 6-week follow-up (10–15 min), $50 for 3-month and 6-month assessments (50–70 min), and a $50 bonus for completing all follow-ups.

Social support

The 12-item Multidimensional Scale of Perceived Social Support (MSPSS; Zimet et al., 1988) was used to subjectively assess participants’ social support in relation to their family, friends, and significant other. For each item, participants rate their agreement on a scale from 1 (very strongly disagree) to 7 (very strongly agree). The MSPSS has demonstrated strong psychometric properties (Zimet et al., 1990), including within U.S. military populations (Campbell & Riggs, 2015; Harper et al., 2020). In the current study, the MSPSS was administered at baseline (Cronbach’s α = .90) and 3-month (Cronbach’s α = .92) and 6-month (Cronbach’s α = .92) follow-ups. Total sum scores are reported for descriptive purposes (possible range: 12–84). Because variances were large in the current sample, mean scores (possible range: 1–7) were included in statistical models.

Treatment utilization

A novel measure of treatment utilization was developed for the parent RCT to assess various forms of PTSD treatment and support. Given the current focus on the utilization of psychotherapy, we examined a variable representing the number of individual therapy sessions completed during a referent period. At each time point, participants were asked, “In the past [referent period], have you talked with a therapist (psychologist, counselor, or social worker) to address concerns related to a traumatic event?” Referent periods were defined as the past 3 months for the baseline and the 6-month assessments and the past 6 weeks for the 6-week and 3-month assessments. If a participant answered “yes,” they were asked, “About how many times in the past [referent period] have you talked with that therapist about concerns related to a traumatic event?” The number of sessions reported at the 6-week and 3-month follow-ups was summed to compute a variable representing the number of sessions in the 3 months before the 3-month assessment. Participants who did not complete the relevant questions at 6-week follow-up (n = 8), 3-month follow-up (n = 9), or both assessments (n = 13) were considered to have missing data for the calculated 3-month variable.

PTSD diagnosis and symptom severity

To determine PTSD diagnosis and symptom severity, study assessors first administered the Life Events Checklist for DSM-5 (Weathers, Blake, et al., 2013a) at baseline, which asks respondents whether they have experienced or been exposed to various potentially traumatic events. Following the identification of an index Criterion A traumatic event (APA, 2013), the assessor administered the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013b; Weather et al., 2018), which is considered the gold standard for clinical PTSD assessment in research contexts. The study assessor rated each of 20 PTSD symptoms on a scale from 0 (absent) to 4 (extreme/incapacitating). This scale allows for both a diagnosis and a total severity score, calculated as the sum of all symptom ratings (possible range: 0–80). Although the CAPS-5 was administered at baseline, 3-months, and 6-months, reciprocal associations with PTSD severity were not a central focus of this study. Thus, only the baseline severity score is reported here and was included in analyses to control for variability in initial levels of distress associated with PTSD upon study entry. In the present sample, Cronbach’s alpha was .74 at baseline.

Data analysis

First, descriptive statistics were examined to characterize the sample. Next, a random-intercept cross-lagged panel model (RI-CLPM; Hamaker et al., 2015) was used to determine the reciprocal relations between social support and treatment utilization. Although alternative modeling approaches were considered (Mund & Nestler, 2019), the RI-CLPM was determined to be the best approach to test the current hypotheses, which were focused on disaggregating within- and between-person effects but did not involve expectations of average developmental trajectories over the 6-month period across all participants.

Following Mulder and Hamaker’s (2021) extensions of the RI-CLPM, several time-invariant predictors were included in the model. Because PTSD severity upon study entry and having abundant mental health resources locally available (as was the case for participants recruited locally) might have impacted both social support and treatment utilization throughout the study, baseline PTSD severity and recruitment source (0 = national, 1 = local) were included as predictors of the random intercepts (i.e., between-person components) for both social support and treatment utilization. Similarly, sex assigned at birth (0 = male, 1 = female) was included as a predictor of both random intercepts given that women tend to experience more negative social responses after trauma (Andrews et al., 2003) and report higher treatment utilization (Maguen et al., 2012). Further, because treatment utilization was a target of the MET intervention, and MET was completed between baseline and 3-month follow-up, the randomly assigned intervention condition (0 = TAU, 1 = MET) was included as a time-invariant predictor of the observed treatment utilization variables at the 3- and 6-month assessments. All time-invariant predictors were allowed to covary.

As described in the Results section, treatment utilization had a large proportion of zero responses. Thus, treatment utilization was modeled as a two-part variable consisting of (a) any therapy sessions attended (0 = no, 1 = yes), and, for participants who attended any sessions, (b) therapy dose, defined as the number of sessions attended (log-transformed; Muthén & Muthén, 2017). To accommodate the two-part variable within the RI-CLPM, a Bayesian approach (Asparouhov & Muthén, 2022) was implemented in Mplus (Version 8.8; Muthén & Muthén, 2017). To iteratively estimate each parameter in a Bayesian approach, Mplus uses Markov chain Monte Carlo (MCMC) algorithms based on the Gibbs sampler (Asparouhov & Muthén, 2010). This approach is computationally efficient, retains cases with missing data, and avoids assumptions of normality.

Bayesian analysis involves updating prior knowledge with current data to determine a posterior distribution for each parameter. However, in the current analyses, prior knowledge was minimal such that noninformative priors were employed, which, therefore, had minimal impact on the posterior distributions. To summarize the posterior distribution of each parameter, the median and 95% credibility interval are reported. The convergence of MCMC chains was evaluated by examining potential scale reduction (PSR) values, trace plots, and posterior parameter distributions (DePaoli, 2021). Model fit was evaluated by examining contingency tables (Asparouhov & Muthén, 2022) and the posterior predictive p value (PPp).

RESULTS

Descriptive statistics

See Table 1 for descriptive information and correlations between study variables. Average social support was above the midpoint at each assessment. Approximately two thirds of the sample (65.8%) reported attending at least one therapy session during the study. However, at any given assessment, a large proportion of the sample denied attending any recent therapy sessions (i.e., 65.2% at baseline, 47.3% at 3 months, and 52.6% at 6 months). Further, although all participants met the diagnostic criteria for PTSD at baseline, there was variability in PTSD severity as assessed using the CAPS-5 (M = 32.91, SD = 8.91, range: 16–64). Regarding index traumatic events, participants most commonly endorsed combat exposure (39.8%) or sexual assault (26.7%); other index events included exposure to suicide (12.4%), serious accidents (10.6%), noncombat physical assault (5.0%), serious illness (2.5%), violent threats (1.9%), child maltreatment (0.6%), and witnessing homicide (0.6%).

TABLE 1.

Descriptive statistics and correlations

Variable Correlations M SD Range
1 2 3 4 5 6 7
1. BL social support (sum) - .67** .64** .03 −.20* −.15 −.11 57.71 14.26 18–84
2. 3m social support (sum) - .74** −.14 −.18* −.27** −.24** 60.15 15.59 18–84
3. 6m social support (sum) - −.15 −.22* −.22* −.21* 63.47 14.92 22–84
4. BL therapy sessionsa - .25** .15 .00 1.38 2.82 0–14
5. 3m therapy sessionsa - .53** .34** 2.47 3.49 0–18
6. 6m therapy sessionsa - .33** 2.55 4.07 0–24
7. BL PTSD severity - 32.91 8.91 16–64
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Note. BL = baseline; 3m = 3-month follow-up; 6m = 6-month follow-up; PTSD = posttraumatic stress disorder.

a

Therapy sessions is the original variable representing total therapy sessions in the past 3 months for concerns related to a traumatic event; this is different from the therapy dose variable in the analyses, which does not include 0 values.

As shown in Table 1, correlations revealed that social support scores at various time points were related to one another. In addition, there was a correlation between the number of therapy sessions attended at neighboring assessments. Correlations between social support and therapy sessions at a given time point ranged from −.22 to .03, p = .012 to .746. Higher levels of baseline PTSD symptom severity were associated with lower social support and more therapy as reported at follow-ups but not baseline.

Longitudinal associations

The RI-CLPM showed evidence of model convergence with 500,000 iterations (thinning = 20), including PSR values at or near 1 (e.g., < 1.001), with no evidence of increasing after burn-in. Model fit appeared acceptable, PPp = .458, with no significant standardized residuals. Model results are shown in Figure 1 (see the Supplementary Materials for all unstandardized estimates and R2 values).

FIGURE 1.

FIGURE 1

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Model results

Note. Solid black lines represent significant estimates (i.e., 95% credibility interval does not contain 0); point estimates are shown for these paths. Solid grey lines represent nonsignificant estimates (i.e., 95% credibility interval contains 0). Dashed grey arrows represent paths fixed to 1. Covariances between time-invariant predictors were estimated but are not depicted here. See the Supplementary Materials for all model estimates.

Between-person associations

Time-invariant predictors.

Partially consistent with expectations, participants with more severe PTSD symptoms at baseline reported a higher likelihood of using any therapy across the study but did not differ in their therapeutic dose. Contrary to expectations, participants recruited from the local military base did not differ from participants recruited nationally in their average ratings of social support or therapy utilization across the study when controlling for baseline PTSD severity and sex. Further, there was a unique effect of sex on treatment utilization such that participants assigned female sex at birth were more likely to use any therapy and have a higher therapy dose across the study. However, sex was not uniquely associated with social support. Also contrary to expectations, random assignment to MET relative to TAU was not associated with the use or dose of therapy at 3 or 6 months.

Between-person covariances.

Controlling for the above-mentioned time-invariant predictors, we examined associations between random intercepts for social support and therapy utilization to determine whether the typical level of social support that a participant reported over the course of the study was associated with their typical therapy utilization. Contrary to expectations, there was no between-person association between social support and therapy utilization (i.e., either any therapy or dose).

Within-person associations

Time-varying predictors.

Within this model, we next examined proximal associations between social support and therapy utilization over time. There was one positive autoregressive association from 3 months to 6 months for social support such that elevated social support at 3 months was associated with higher levels of social support at 6 months. Contrary to our hypotheses, cross-lagged associations revealed that greater social support at 3 months was associated with a lower likelihood of reporting any therapy utilization at 6 months. There were no other within-person associations between social support and therapy utilization.

Within-person covariances.

Contemporaneous covariances were estimated for all variables at each time point. Only one unique cross-sectional association was found between social support and any therapy utilization at baseline; this association did not extend to therapy dose or subsequent time points.

DISCUSSION

This was the first known longitudinal study to examine reciprocal relations between social support and treatment utilization among an active duty military sample with PTSD. We expected that positive associations between social support and treatment utilization would be robust and apparent, on average, across the study (i.e., between-person) and also from one time point to the next (i.e., within-person). However, associations were only supported at the within-person level, suggesting the importance of more proximal time-specific associations instead of stable individual factors. These within-person associations revealed that higher levels of perceived social support were associated with a higher likelihood of concurrent therapy use at baseline, consistent with our expectations. However, the only significant prospective within-person association revealed a different association such that there was a negative relationship between social support and subsequent therapy use. These findings add to the mixed literature while clarifying a specific prospective linkage within a difficult-to-reach sample of active duty service members.

Although it was contrary to our expectations, the negative within-person prospective association between social support and the subsequent utilization of any therapy—but not dose—has several potential explanations. One possibility is that service members with PTSD and low social support may have been motivated to connect with a therapist in pursuit of social connection and support, but this motivation may not have been enough to promote ongoing engagement in more regular therapy sessions. Interpreted in the context of the health belief model (Carpenter, 2010; Rosenstock, 1966), low social support itself may be perceived as a negative state motivating change, and some individuals may believe therapy will mitigate this problem by providing a source of support. For some participants, therapists and social supporters may have served similar functions. That is, formal providers, like therapists, may have provided some degree of social support when support from partners, family members, and/or friends was lacking. Similarly, social support networks may have served as informal or lay treatment networks (Gottlieb, 1976). For example, in past research, soldiers in need of mental health care have reported using nonproviders, such as fellow soldiers, to meet their needs (Kim et al., 2016). In this context, service members with PTSD may have similarly reached out to trusted individuals in their social network for guidance and advice about symptom management and might not have felt a need to seek therapy.

Another possibility is that the effect of social support on treatment utilization may depend more on the nature of support than the absolute level of perceived support, which was the focus of the current study. For example, having people in one’s social network who actively encourage treatment has been associated with PTSD treatment utilization in past research (Spoont et al., 2014; Zinzow et al., 2015). Similarly, contact with someone who has sought care may reduce stigma (Hipes, 2011) and facilitate treatment utilization, particularly if that person shares a positive treatment experience. On the other hand, when trying to assist someone with PTSD, individuals in a social support network may respond in ways that are unsolicited, unwanted, or unhelpful (Beehr et al., 2010), which may discourage treatment utilization. For example, well-intentioned military peers or significant others may share concerns about career harm following treatment-seeking and, thus, may be supportive of the individual while actively discouraging treatment-seeking. To gain more specificity in how social support may impact treatment utilization, future researchers could examine each social network member’s general supportiveness, specific support for treatment, and the behaviors that most effectively facilitate therapy use and adequate treatment dose.

In the current study, we also expected associations between social support and treatment utilization to be reciprocal. However, contrary to expectations, treatment utilization was not associated with subsequent social support. Although evidence-based treatments, such as behavioral activation, have been shown to increase social support in the short term among veterans (Campbell et al., 2019), participants in the current study had no constraints on the modality or format of psychotherapy they received. Although they were provided with referral information for empirically supported treatments for PTSD, as well as other forms of treatment, the strategies utilized in the therapy sessions were unknown and may not have involved strategies to promote interpersonal engagement or exposures to social settings. Even if evidence-based strategies for PTSD were used, these may not have been as effective as desired (Steenkamp et al., 2015), especially for military populations (Straud et al., 2019). Thus, additional work is needed to determine which, if any, PTSD intervention strategies may promote social support in ways that are robust to the challenges active duty service members experience.

In the context of the longitudinal model, we also examined how each variable was related to itself over time. As one might expect, higher levels of social support at 3 months, after controlling for baseline levels, were associated with higher levels of subsequent social support at 6 months, suggesting the persistence of social support. On the other hand, treatment utilization was not related to itself over time, which may speak to the sporadic nature of therapy engagement in this population. This could reflect the use of short-term, time-limited treatments, which would not be expected to lead to long-term treatment utilization. Conversely, this could reflect difficulties with staying engaged in therapy for this population. As noted previously in the context of the health belief model (Carpenter, 2010; Rosenstock, 1966), perceived barriers can interfere with treatment utilization, and service members often encounter a range of perceived and practical barriers to engagement in mental health care, potentially including deployments or other work-related responsibilities that interfere with attending regular sessions as well as an inconsistent availability of services. Future studies should evaluate if individuals receive the recommended dose of a given treatment (Britt et al., 2015) and whether low session attendance reflects either premature treatment dropout or treatment completion (Edwards‐Stewart et al., 2021).

Several time-invariant predictors were also considered as covariates within the longitudinal model. Although all participants met the diagnostic criteria for PTSD at baseline, those who reported more severe PTSD symptoms at this time reported a higher likelihood of any therapy and a higher dose, on average, across the study. This finding is consistent with a broader literature suggesting that more severe PTSD symptoms are associated with treatment utilization (Johnson & Possemato, 2019). We also considered recruitment source but found no difference in average social support or treatment utilization between participants who were recruited locally and nationally. Consistent with past work (Maguen et al., 2012), female participants reported higher degrees of therapy utilization (any therapy and dose) relative to male participants. However, there were no sex differences in social support when controlling for PTSD severity and recruitment source. Finally, random assignment to MET, relative to TAU, was not associated with differences in therapy use or dose at follow-up assessments. MET was designed to promote treatment-seeking and engagement, broadly defined, and did not focus specifically on individual therapy. In fact, some participants who had a successful outcome of MET may have reduced their contact with one therapist (e.g., a therapist who provided supportive care that intermittently touched on trauma but did not target PTSD using evidence-based strategies) to begin trauma-focused treatment. Further, individuals may have begun pursuing therapy services during the study timeframe but may have been subject to waitlist periods or other delays beyond their control. For a more comprehensive examination of the effects of MET on treatment-seeking in the current sample, see Walker et al. (2022).

The study findings should be understood in the context of several limitations. First, the sample was recruited for a parent RCT. Thus, the sample size was determined by the power needed to detect primary outcomes in the parent trial, and null findings of the current secondary analyses should be interpreted with caution. Further, this was an active duty military sample. Although participants presented with a wide array of index traumatic events, most reported PTSD linked to combat exposure or sexual assault, as is common in military samples (Jakob et al., 2017). The military social environment is unique relative to civilian contexts for its focus on creating a cohesive fighting force (Siebold, 2011), geographic separation from civilian support systems (Meyer, 2015), and repeated deployments to combat or new duty stations (Redmond et al., 2015). In addition, although active duty personnel have access to mental and behavioral health providers, they can encounter stigma, a risk of harm to their career, and barriers to services that are unique to the military context (Hom et al., 2017). Therefore, it is unclear whether the present findings extend to civilians. In addition, this sample was unique in that participants were not engaged in trauma-focused therapy but were willing to participate in a PTSD-focused clinical study. Thus, at baseline, some may have been considering treatment whereas others were actively involved in therapy that was not focused on trauma.

In addition, there were limitations to the study measures. Sessions were assessed only in reference to a therapist with whom the participant discussed a potentially traumatic event. Thus, therapy utilization for topics the participant did not perceive as related to the trauma was not captured here. One possibility is that participants’ perception of therapy as trauma-related may have increased over the course of the study, with repeated assessments of their trauma symptoms. Relatedly, participants may not have been aware of their need for PTSD treatment and, thus, sought services for other conditions. Anecdotally, we often heard from participants that they wanted to address depression or anxiety but were sometimes unaware that they had a PTSD diagnosis or preferred to avoid discussing their traumatic experience. As such, individuals could have sought therapy sought to address symptoms of PTSD, such as anxiety, that were not captured in our data, which focused on therapy in which the participant discussed the traumatic event. Alternatively, treatment for PTSD may have not been available, as is common in many communities. Further, part of the recruitment and follow-up periods were within the COVID-19 pandemic, which may have affected treatment availability and, thus, utilization. Future studies could also assess the availability of trauma treatments.

In sum, the findings highlight the complex associations between PTSD-related treatment utilization and social support. Initial social support was associated with a higher likelihood of trauma-related treatment utilization at baseline. However, prospective findings revealed a different pattern. When social support was higher, subsequent engagement in therapy addressing the traumatic event was less likely. Social networks provide informal sources of mental health support, in both positive and negative ways. Clinical interventions have underutilized social supporters as a potential means of providing guidance around referral and treatment options or potential sources of low-intensity treatments. Future research should explore interventions regarding reducing mental health stigma and facilitating shared decision-making targeted toward social networks as a further way of boosting PTSD treatment utilization.

Supplementary Material

Supplement

Acknowledgments

This study was supported by a grant from the Department of Defense Congressionally Directed Medical Research Programs (CDMRP; Research Grant W81XWH-17-1-0002; to Drs. Denise Walker and Debra Kaysen). The funding agency had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the article. The views expressed in this article are those of the authors and do not necessarily reflect the positions or policies of academic institutions, the Department of Veterans Affairs, or the Department of Defense.

Footnotes

The trial was registered on ClinicalTrials.gov (NCT03423394).

The authors have no conflicts of interest to declare.

OPEN PRACTICES STATEMENT

The protocol for the parent clinical trial is available at Kaysen et al. (2022; ClinicalTrials.gov identifier: NCT03423394). The secondary analysis reported in this article was not formally preregistered. Neither the data nor the materials have been made available on a permanent third-party archive; requests for the data or materials can be sent via email to Dr. Denise Walker (ddwalker@uw.edu) or Dr. Debra Kaysen (dkaysen@stanford.edu).

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