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Journal of Military, Veteran and Family Health logoLink to Journal of Military, Veteran and Family Health
. 2023 Mar 13;9(2):40–51. doi: 10.3138/jmvfh-2022-0048

Impact of morally injurious traumatic event exposure on cognitive processing therapy outcomes among Veterans and service members

Stefanie T LoSavio a, Willie Hale b, Casey L Straud a, Jennifer Schuster Wachen c, Jim Mintz a, Stacey Young-McCaughan a, Sarah N Vacek b, Jeffrey S Yarvis d, Denise M Sloan e, Donald D McGeary a, Daniel J Taylor f, Terence M Keane e, Alan L Peterson a, Patricia A Resick g
PMCID: PMC13293140  PMID: 42533938

Lay Summary

Military personnel frequently report actions taken by themselves or others that violate deeply held moral beliefs, which can be experienced as a kind of moral injury. Some have questioned whether existing treatments for posttraumatic stress disorder (PTSD), such as cognitive processing therapy, are effective for those who have been exposed to a morally injurious traumatic event. These analyses demonstrate that active duty service members and Veterans seeking treatment for PTSD who reported potentially morally injurious trauma had PTSD and depression outcomes that were as good as those whose traumas were not primarily seen as morally injurious, suggesting that cognitive processing therapy is an efficacious treatment for PTSD in the context of morally injurious trauma.

Key words: active duty, cognitive processing therapy, CPT, military, moral injury, posttraumatic stress disorder, PTSD, Veterans

Abstract

Introduction:

Cognitive processing therapy (CPT) is recommended for the treatment of posttraumatic stress disorder (PTSD) and effective across a range of trauma types. However, some have questioned whether CPT is effective for morally injurious traumas, including perpetrating, failing to prevent, witnessing, or learning of acts that transgress moral beliefs and expectations. The aims of this analysis were to examine whether treatment-seeking active duty service members and Veterans with and without potentially morally injurious traumatic events had differences in CPT outcomes.

Methods:

Data were pooled from five clinical trials in which active duty service members and Veterans received CPT. Non-inferiority analyses were used to compare rates of receiving an adequate dose of treatment (i.e., eight sessions or a PTSD Checklist-5 score < 20 at the final session) and improvement in PTSD and depression symptoms.

Results:

More than 70% of participants received an adequate dose, and those with a potentially morally injurious trauma were no less likely to receive an adequate dose. Both those with and without a potentially morally injurious trauma experienced significant reductions in PTSD and depressive symptoms (all ps < 0.001), and reductions among those with a potentially morally injurious trauma were non-inferior to those without a morally injurious trauma.

Discussion:

Findings indicate that active duty military personnel and Veterans endorsing traumas primarily characterized by moral violation engage in and benefit from CPT similarly to those not endorsing such traumas. Results suggest that CPT is a good PTSD treatment option for military personnel with morally injurious trauma.

Introduction

Cognitive processing therapy (CPT) is a first-line, recommended cognitive-behavioural treatment for post-traumatic stress disorder (PTSD) in which the therapist helps the patient examine beliefs about the causes and consequences of their trauma and feel their natural emotions to facilitate recovery.1–3 CPT has been shown to be efficacious for civilians, Veterans, and active duty service members across a range of trauma types.4–9 How ever, researchers and clinicians have raised the question of whether PTSD treatments such as CPT are sufficient for individuals who experienced morally injurious traumatic events,10–13 which are experiences characterized by “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.”11(p.700) For example, it has been suggested that PTSD models and intervention strategies are appropriate for traumas involving personally experiencing life threat or harm by others but may be inadequate to address harm resulting from perpetration or other moral transgressions.11

Military personnel, including active duty service members and Veterans, experience particularly high rates of exposure to morally injurious events.11 For example, a substantial proportion of service members deployed in support of operations in Iraq and Afghanistan reported directing fire at or being responsible for the death of enemy combatants and non-combatants, seeing others whom they were unable to help, and handling human remains.14 A study of Iraq Veterans indicated that 40% reported killing in combat.15 Some have raised the question of whether the less pronounced symptom response among military personnel observed during PTSD treatment may be due to exposure to morally injurious traumas and whether these individuals need a different treatment approach.12,16–18

The question of CPT’s appropriateness for individuals with moral injury likely stems from the fact that CPT often involves helping patients reduce erroneous self-blame for traumas in which they were harmed by someone else or that were unforeseeable or uncontrollable. As a result, some have wondered whether CPT is appropriate for patients who hold responsibility for their traumatic event or did not act in situations in which harm could have been prevented.10,11 Wachen et al. discussed how CPT would be applied to service members with moral injury,19 noting that therapists can use Socratic questioning to gather information about the event to help a patient determine whether thoughts are an accurate interpretation of the situation and, in a case in which self-blame is appropriate (e.g., harm was intended), acknowledge this reality and facilitate processing of natural emotions.

Although these conceptual considerations have led to important discussion, empirical data on the effectiveness of CPT for individuals with morally injurious traumas have been limited. Such data would be informative and address CPT’s utility with this important population. In one illustrative case study, Held et al. presented PTSD and depression outcomes for a treatment-seeking combat Veteran who received orders to kill a child in combat.20 During treatment with CPT, the Veteran had a 52-point reduction in PTSD symptoms, ending with a score of 13 on the PTSD Checklist for DSM-5 (PCL-5),21 which indicates a good clinical end state and a low likelihood of meeting criteria for PTSD. Depression scores on the Patient Health Questionnaire (PHQ-9) also improved,22 dropping 9 points and ending at a 4, indicating minimal depression.

Held et al. also examined the impact of morally injurious traumatic event exposure on treatment completion and PTSD and depression outcomes using clinic data collected from service members and Veterans receiving CPT as part of an intensive treatment program that also included additional behavioural interventions (i.e., mindfulness, yoga, psychoeducation, and case management).23 They found no differences in treatment completion rates or symptom improvement on the basis of having exposure to a morally injurious trauma or having a morally injurious event as one’s index trauma during CPT. PTSD and depression remission did not differ between those with and without a morally injurious trauma.

Litz et al. conducted a randomized clinical non-inferiority trial among active duty service members that compared CPT with adaptive disclosure, an intervention designed to address military culture and moral-injury-related trauma.24 Both treatments were associated with large decreases in PTSD symptoms, and no differences were found between treatments in PTSD, depression, or functional outcomes. Although the results require replication with a larger sample, they suggest that the effects of CPT on PTSD and depression in a population experiencing a high rate of moral injury were comparable with those of a treatment specifically designed to address moral injury.

Taken together, studies indicate that CPT is efficacious in the treatment of PTSD for individuals who have experienced morally injurious traumas. However, research in this area is limited, and no previous studies have compared the outcomes of individuals with and without morally injurious traumas receiving treatment as part of a clinical trial or among individuals who received CPT only. The aims of this analysis were to pool data from five clinical trials that included CPT as an intervention for treatment-seeking active duty military personnel and Veterans to compare PTSD and depression treatment outcomes of those endorsing versus not endorsing a trauma primarily characterized by moral violation. Hypotheses were as follows: 1) treatment outcomes for those endorsing exposure to potentially morally injurious traumas would be non-inferior to those not endorsing exposure to morally injurious traumas with respect to receiving an adequate dose of treatment (i.e., eight sessions or a PCL-5 score < 20 at the final session) and 2) treatment outcomes for those endorsing exposure to potentially morally injurious traumas would be non-inferior to those not endorsing exposure to such traumas with respect to PTSD and depression symptom improvement.

Methods

Participants

Participants were 457 treatment-seeking, active duty service members and Veterans who participated in one of five clinical trials that occurred under the auspices of the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR) Consortium or Consortium to Alleviate PTSD (CAP).25 The parent studies included a randomized non-inferiority trial of CPT versus written exposure therapy among active duty military personnel,26 a randomized trial of CPT delivered in office, in home, or via telehealth among active duty service members and Veterans,27 a randomized trial of CPT compared with headache treatment among Veterans with PTSD and posttraumatic headache,28 a trial of variable-length CPT among active duty military,25 and a randomized trial of CPT only or CPT preceded or followed by treatment for sleep and insomnia for active duty service members and recently discharged Veterans.29

Data included in this analysis were from those participants who received CPT only and no other interventions. When studies provided CPT plus other interventions, data were included from only those participants who received CPT only or from participants before they received other interventions. Data were included from participants who received CPT in person or telehealth given previous research that these formats produce comparable outcomes (see Morland et al. for a review).30 See Table 1 for sample demographics.

Table 1.

Demographic characteristics

Characteristic Total sample (N = 457) Morally injurious trauma (n = 57) Non-morally injurious trauma (n = 400) t, χ2 p
Age, mean (SD) 37.48 (8.96) 35.81 (8.43) 37.72 (9.01) 1.490 0.137
Years in military, mean (SD) 14.13 (7.39) 12.46 (6.46) 14.37 (7.48) 1.832 0.068
Gender, % 2.620 0.105
 Male 84.5 11.4 88.6
 Female 15.5 18,3 81,7
Education, % 4.390 0.111
 High school or less 13.8 15.9 84.1
 Some college/associate’s degree 59.0 14.1 85.9
 College or graduate degree 27.2 7.3 92.7
Branch, % 1.988 0.575
 Army 86.2 11.9 88.1
 Marines 5.5 20.0 80.0
 Air Force 4.6 9.5 90.5
 Navy 3.7 17.6 82.4
Military pay grade, % 4.937 0.176
 E-1 to E-3 2.6 16.7 83.3
 E-4 to E-6 59.7 15.0 85.0
 E-7 to E-9 28.9 7.6 92.4
 WO-1 to O-5 8.8 10.0 90.0
Typical duty, % 0.697 0.706
 Combat arms 39.7 12.8 87.2
 Combat support 22.4 13.4 86.6
 Combat service support 37.9 10.4 89.6
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Note: The two groups did not differ on any demographic variables; therefore, none were included as covariates in any of the reported models.

Procedure

This was a secondary analysis of previously collected clinical trials data. Details of the parent trials are reported elsewhere.26–29,31 All of the parent studies received internal review board approval and oversight at the participating sites, and all participants provided informed consent. Consistent with STRONG STAR and CAP procedures, all participants were assessed by independent evaluators and diagnosed with PTSD. A deidentified version of the combined datasets was used to conduct the current analyses.

CPT is a trauma-focused, cognitive-behavioural treatment (primarily cognitive) in which therapists help patients examine thoughts related to their traumatic experience that are interfering with their recovery using Socratic questioning and a series of progressive worksheets.3 Patients are guided to examine the facts of the event and experience associated natural emotions.3 CPT is based on the information processing theory of PTSD, and its theorized mechanisms are cognitive processing (e.g., resolving discrepancies between pre-trauma beliefs and the meaning of the trauma) and facilitation of natural emotions (experiencing, instead of avoiding, emotions that match the facts of the situation).3 Participants in the included studies were offered 12 sessions of CPT,26–29 18 sessions of CPT,29 or a variable number of sessions of CPT until reaching a good clinical end state (PCL-5 score < 20), up to 24 sessions.31 All participants received CPT in an individual format. Adherence to the CPT protocol was monitored in each trial and, among the published parent trials, was greater than 89.0%,27,28,31 for example, 98.6%,31 98.9%,27 and “good to excellent.”26,31

Measures

Exposure to potentially morally injurious trauma

Exposure to potentially morally injurious trauma was determined by participant report. During a pretreatment assessment, participants were assessed for exposure to potentially traumatic events and asked about their worst traumatic events. Regarding those events, participants were asked, “What were the worst parts of this event?” Response options were as follows: 1) “You thought that you could be seriously injured or killed,” 2) “You thought that someone else could be seriously injured or killed,” 3) “The sights, sounds, and smells of the event,” 4) “A friend or unit member was killed,” 5) “You acted in ways that violated your own moral code or values,” and 6) “Someone else acted in ways that violated your own moral code or values.” Participants could select up to three items, which were rank ordered for up to three traumatic events. For conceptual clarity, the authors categorized individuals as positive for exposure to a potentially morally injurious traumatic event if they indicated that option 5 or 6 was the most distressing part of any of their reported worst events. This was done to capture individuals who viewed the violation of their moral code or values as the primary feature of their experience.

Posttraumatic stress disorder symptoms

PTSD diagnosis was assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5),32 which is considered a gold-standard assessment. The CAPS-5 reflects the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5).33 Items are rated on a scale ranging from 0 (absent) to 4 (extreme/incapacitating). The CAPS-5 has demonstrated strong internal consistency, inter-rater reliability, test-retest reliability, and convergent and discriminant validity.34

PTSD symptoms were assessed via self-report using the PCL-5,21 which is a 20-item scale reflecting the 20 DSM-5 criteria for PTSD.33 Throughout treatment, respondents rated how much they were bothered by symptoms during the past week on a scale ranging from 0 (not at all) to 4 (extremely). The PCL-5 has demonstrated good internal consistency, test-retest reliability, and convergent and discriminant validity.35

Depression symptoms

Depression symptoms were assessed using the PHQ-9,22 which is a nine-item self-report scale. Throughout treatment, respondents rated how much they were bothered by each symptom during the past two weeks on a scale ranging from 0 (not at all) to 4 (nearly every day). Total scores of 5, 10, 15, and 20 are cut-points for mild, moderate, moderately severe, and severe depression, respectively. The PHQ-9 has demonstrated good internal and test-retest reliability and convergent, discriminant, and criterion validity.22

Adequate dose

For the purposes of these analyses, an adequate dose was defined as completing eight or more sessions of CPT or, because of the varying lengths of CPT in the parent trials and consistent with recent shifts in the field to focus on a good end state,31,36–38 achievement of a PCL-5 score of < 20 at their last treatment session.

Data-analytic strategy

The authors combined those who endorsed either type of potentially morally injurious trauma (i.e., perpetrated by themselves or someone else) into a single group for analysis to ensure an adequate sample size for comparison. Exposure to potentially morally injurious trauma (trauma that was primarily distressing because of a violation of their moral code or values) was endorsed by 12.5% of participants (57/457) and included either moral violation by self (6.1%; 28/457) or by another person (6.3%; 29/457). Demographics for each group (potentially morally injurious trauma and not primarily morally injurious trauma) are presented in Table 1. The groups did not differ on any of the variables assessed.

To get estimates of the proportion who received an adequate dose of treatment among those with potentially morally injurious trauma exposure versus those without primarily morally injurious trauma exposure, a χ2 difference test was conducted. To attain estimates of change over time on the PTSD and depression measures, mixed-effects regression models with repeated measures using unstructured covariance matrices were examined. These models included fixed effects of time and group (potentially morally injurious trauma vs. not primarily morally injurious trauma) and their respective interaction. Specific contrasts were examined to attain estimates of the standard error of the between-groups difference of the within-group change estimates, which were used as part of the non-inferiority tests. Neither treatment study nor active duty status was associated with whether events were rated as primarily distressing because of moral violation, attainment of a good outcome, or changes in PTSD or depression scores; thus, these variables were not included in our reported models. All tests were conducted using IBM SPSS Statistics (version 28).

Hypotheses were that outcomes of those with potentially morally injurious traumatic event exposure would be non-inferior to outcomes of those without such exposure with respect to receipt of an adequate dose of treatment (Hypothesis 1) and PTSD and depression symptom reduction (Hypothesis 2). These hypotheses were tested using the confidence interval approach based on the two one-sided tests (TOST) method. Under this method, non-inferiority is established if the upper and lower bounds of the two-sided 95% confidence intervals of the mean difference lie completely to the left or right (depending on how the group differences are defined) of a predetermined non-inferiority margin (δ) representing a clinically important difference. Non-inferiority was considered established if the lower end of the between-groups difference’s confidence interval was greater than the specified margin. On the basis of previous research, including the reliable change index from the parent trials, when reported, the non-inferiority margins for these analyses were set a priori as 10 points on the PCL-5,27,31 7 points on the PHQ-9,24,39 and a difference of 10% on receipt of adequate dose.7 Results from the full intention-to-treat sample are presented.

Results

Hypothesis 1 was that treatment outcomes for those who endorsed potentially morally injurious traumatic event exposure would be non-inferior to those without such exposure with respect to receiving an adequate dose of treatment. This hypothesis was supported. As can be seen in Table 2, 70.2% of participants in the potentially morally injurious trauma group received an adequate dose of CPT, as did 72.6% of those in the non-morally injurious trauma group. The 2.4% difference can be considered non-inferior because the lower limit of the confidence interval is greater than the predetermined margin of −10%.

Table 2.

Differences within and between groups from intention-to-treat analysis for non-inferiority hypotheses

H: Comparison of outcomes WG value BG diffs SEdiff TOST
 Margin Decision
LCL UCL
H1: % adequate dose
 Morally injurious trauma 70.20 2.40 6.50 −8.30 13.00 −10 Morally injurious trauma group not inferior
 Non-morally injurious trauma 72.60
H2: Change in PCL-5
 Morally injurious trauma −17.58 2.34 3.20 −2.93 7.60 −10 Morally injurious trauma group not inferior
 Non-morally injurious trauma −15.24
H2: Change in PHQ-9
 Morally injurious trauma −4.57 1.41 1.18 −0.54 3.36 −7 Morally injurious trauma group not inferior
 Non-morally injurious trauma −3.16
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H = hypothesis; WG = within-group; BG = between groups; diffs = differences; SEdiff = standard error of the between-groups difference; TOST = two one-sided tests; UCL = upper bound of 95% confidence interval; LCL = lower bound of the 95% confidence interval; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire.

Hypothesis 2 was that the amount of PTSD and depressive symptom reduction attained by the group with potentially morally injurious trauma exposure would be non-inferior compared with that attained by group without such exposure. This hypothesis was supported as well. Tests showed that the group × time interaction was not significant for the models examining change in PCL-5 scores (F1, 333.93 = 0.53, p = 0.47) or PHQ-9 scores (F1, 264.31 = 1.42, p = 0.23), and simple main effects showed that each group experienced a significant decrease on both measures (all ps < 0.001; see Figure 1). As can be seen in Table 2, the lower limit of the TOST confidence interval was greater than the predetermined non-inferiority margin, indicating that outcomes for the potentially morally injurious trauma group can be considered non-inferior to those for the non-morally injurious trauma group.

Figure 1.

Changes in PTSD and depression symptoms by morally injurious and non-morally injurious trauma exposure for the intention-to-treat sample

Figure 1.

PTSD = posttraumatic stress disorder; PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire-9.

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Discussion

With data from five clinical trials of active duty service members and Veterans with PTSD, the authors examined whether rates of receiving an adequate dose of treatment and degree of PTSD and depression symptom improvement achieved during CPT differed as a function of traumatic event exposure that was perceived as primarily distressing because it involved a violation of one’s moral code or values. Results indicated that those endorsing exposure to a traumatic event primarily characterized by moral violation (12.5% of the overall sample) were no less likely to receive an adequate dose of treatment (at least eight sessions or attainment of a good clinical end state) and no less likely to improve on PTSD and depression symptoms. The difference between groups was well within the non-inferiority margin, and the same conclusions would have been made even had a narrower margin been used. Both groups had significant reductions in symptoms, and a large proportion (> 70%) had an adequate dose of treatment.

This study adds to the growing literature that CPT is effective and efficacious in the treatment of PTSD resulting from a wide range of traumas, including those characterized by moral violation.23,24 Although many clinicians have concerns about for whom CPT and other trauma-focused treatments can be effective,40 studies provide evidence for the robustness of CPT out-comes across a wide range of settings and populations.41 Non-inferiority on receiving an adequate dose might also suggest that service members and Veterans who experienced a potentially morally injurious trauma found CPT tolerable and acceptable.

Although some have questioned whether existing PTSD treatments can address the complexity of morally injurious traumas, these results suggest that the strategies in CPT are effective for PTSD among this population. In some respects, CPT is an ideal strategy to use to explore morally injurious traumas because it involves making sense of an event that is discrepant with beliefs about how the world is supposed to work. Socratic questioning is a valuable tool for exploring the context and facts of traumatic experiences without assumptions about culpability.

Participants whose data are reported here were seen by study therapists who received clinical consultation on their cases. It could be the case that therapists in routine care settings feel less certain about how to approach morally injurious traumas. The CPT manual discusses applications of the model to cases in which guilt may be appropriate, such as acting to harm others or not preventing harm (see “Differentiating among Intention, Responsibility, and the Unforeseeable,” “Combat and the Warrior Ethos,” and “Religion and Morality” sections).3 However, readers are also encouraged to review examples and case studies of CPT approaches for morally injurious trauma.19,20,42 In addition, clinical consultation has been shown to improve clinician outcomes,43 so participation in consultation on CPT cases is recommended for clinicians who are not yet experienced in CPT or its application to individuals with morally injurious trauma.

Although CPT is a good choice of treatment for PTSD from a trauma involving moral violation, other evidence-based treatments may also be appropriate. Prolonged exposure is another evidence-based treatment for PTSD that can be applied to morally injurious traumas.20,44,45 Adaptive disclosure was found to be non-inferior to CPT among service members with PTSD and therefore may also be a good treatment choice.24 Fortunately, despite the distress and functional impairment associated with PTSD involving moral injury, multiple treatment options are available.46

Strengths and limitations

Strengths of this study include the use of a large pool of data from multiple, well-designed clinical trials. Another strength is that the authors used participant reports of whether an event violated moral values to operationalize exposure to potentially morally injurious trauma. Given the subjectiveness of moral injury, this approach is preferred over other strategies, such as researchers retrospectively coding for moral injury on the basis of trauma type. However, moral injury is a complex phenomenon, and the authors did not assess the breadth of moral-injury-related constructs that may be part of a more multidimensional moral injury assessment, such as feelings of betrayal, loss of meaning and purpose, self-condemnation, or religious struggles.47 These analyses as well as those of previous studies have focused on out-comes of PTSD, depression, and functioning;23,24 how ever, less is known about other moral injury outcomes. Therefore, future research should assess the effectiveness of CPT and other evidence-based treatments across the full spectrum of issues commonly reported by individuals who have experienced morally injurious traumas, including using moral injury outcomes assessments.47 This study adds to the understanding of the efficacy of CPT for PTSD and depression, but future research will be needed to assess the effects of CPT on moral-injury-specific outcomes.

In addition, the authors combined actions taken both by oneself and by someone else that violated one’s moral code or values into one category to ensure an adequate sample size for comparisons. However, future research may focus more on examining different types of morally injurious events. Finally, available data do not include systematically collected qualitative information about whether and how CPT delivery might have differed for individuals with, versus without, a trauma characterized by a moral violation. Providers have flexibility within the protocol to identify and select beliefs to examine and whether to assist clients in developing more realistic beliefs or work toward acceptance and feeling natural emotions associated with accurate beliefs. In addition to some already published examples,20 the field would benefit from additional accounts of CPT delivery for clients exposed to morally injurious events, including how approaches may be similar to and different from events not characterized by morally injurious experiences.

Conclusion

CPT is an efficacious treatment for PTSD and depression among those with and without potentially morally injurious traumatic events. CPT should be considered for the treatment of PTSD, including in cases in which the individual’s trauma was perceived as a moral violation.

Biographies

Stefanie T. LoSavio, PhD, ABPP, serves as Associate Director of the South Texas Research Organizational Network Guiding Studies on Trauma and Resilience (STRONG STAR) Training Initiative and Assistant Professor of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at San Antonio. She provides clinical training and studies strategies to improve the reach and effectiveness of evidence-based treatments for posttraumatic stress disorder.

Willie Hale, PhD, currently works as an assistant professor at the University of Texas at San Antonio. He oversees the Investigating Models of Psychological Adjustment, Coherence, and Trauma Lab. His research focus is on investigating psychosocial factors that contribute to the onset, maintenance, and treatment of posttraumatic stress disorder and related conditions.

Casey L. Straud, PsyD, ABPP, is a board-certified psychologist, assistant professor in the Department of Psychiatry and Behavioral Sciences, and member of the STRONG STAR Consortium at the University of Texas Health Science Center at San Antonio, with appointments at the University of Texas San Antonio and South Texas Veterans Health Care System. His research focuses on enhancing posttraumatic stress disorder treatment outcomes through biological and pharmacological mechanisms, with an emphasis on the endocannabinoid system. He also has a background in biostatistics.

Jennifer Schuster Wachen, PhD, is a clinical psychologist in the Women’s Health Sciences Division of the National Center for PTSD at VA Boston Healthcare System and an Associate Professor in the Department of Psychiatry at Boston University School of Medicine. Her Department of Defense-funded research focuses on optimizing cognitive processing therapy (CPT) in military populations. She is a trainer and consultant in CPT and serves as a consultant for the Department of Veterans Affairs PTSD Consultation Program.

Jim Mintz, PhD, is a research methodologist and applied biostatistician. He held the Dielmann Distinguished Professorship for Advanced Methods at the University of Texas Health Science Center at San Antonio. He retired in 2022 after a 55-year career during which he published more than 600 articles, directed biostatistics and data cores, and was co-investigator on numerous research projects. He was a member of National Institute of Mental Health review committees, president of an international research society, and mentor to colleagues.

Stacey Young-McCaughan, PhD, RN, is a nurse scientist and Professor in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at San Antonio. Young-McCaughan is a retired Army Nurse Corps Officer who served 29 years. She has been the director of research for the STRONG STAR Consortium, a multidisciplinary network that develops and evaluates interventions for the prevention, diagnosis, and treatment of psychological health conditions in military personnel, Veterans, and first responders.

Sarah N. Vacek, MS, is a second-year doctoral student in the Department of Psychology at the University of Texas at San Antonio. Her research interests include the impact of childhood trauma on adult well-being, the onset and development of posttraumatic stress disorder, and investigating interactions between psychosocial factors to better predict military health outcomes.

Col. (retd) Jeffrey S. Yarvis, PhD, is a decorated combat Veteran with 34 years of service as a distinguished social worker and military scholar and more than 100 peer-reviewed publications and 150 conference proceedings. A lifelong educator, Yarvis was named a 2021 National Association of Social Workers Pioneer in social work for his advocacy and humanitarian efforts. He recently published a book with Oxford University Press called Combat Social Work: Applying the Lessons of War to the Realities of Human Services. Yarvis is now at Tulane University.

Denise M. Sloan, PhD, is the associate director of the Behavioral Science Division, National Center for PTSD, and a professor of Psychiatry at Boston University Chobanian & Avedisian School of Medicine. She is an expert on psychosocial interventions for traumatic stress disorders and has a specific interest in efficient treatments for posttraumatic stress disorder. Sloan has published more than 150 journal articles, serves as editor-in-chief of the Journal of Traumatic Stress, and is a consulting editor for six scientific journals.

Donald D. McGeary, PhD, ABPP, is a professor with tenure and Vice Chair for Research in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at San Antonio. He is also a research health scientist with the South Texas Veterans Healthcare System. Before his current positions, McGeary spent 10 years in civil service with the U.S. Air Force and the U.S. Army.

Daniel J. Taylor, PhD, DBSM, DABSM, is a professor of psychology and Director of Clinical Training at the University of Arizona. He is Diplomate of Sleep Medicine and Behavioral Sleep Medicine and a Fellow of the Society of Behavioral Sleep Medicine. His observational research examines comorbid sleep disorders (i.e., insomnia, nightmares, and circadian rhythm) as modifiable risk factors for increased medical or mental health problems. His clinical trials research focuses on the efficacy and effectiveness of treating comorbid sleep disorders.

Terence M. Keane, PhD, is Director of the National Center for PTSD Behavioral Sciences Division and Associate Chief of Staff for Research & Development at VA Boston Healthcare System. He is Professor of Psychiatry and Assistant Dean for Research at Boston University School of Medicine. Keane has published more than 400 articles on the assessment and treatment of posttraumatic stress disorder. For the past 43 consecutive years, his program of trauma research has been supported by federal funding agencies.

Alan L. Peterson, PhD, ABPP, is a professor and Chief of the Division of Behavioral Medicine in the Department of Psychiatry and Behavioral Sciences at the University of Texas Health Science Center at San Antonio. He is the Director of the STRONG STAR Consortium, which includes more than 150 research collaborators and 50 institutions worldwide. He served on active duty in the U.S. Air Force for 21 years and deployed in support of Operations Noble Eagle, Enduring Freedom, and Iraqi Freedom.

Patricia A. Resick, PhD, ABPP, is Professor of Psychiatry and Behavioral Sciences at Duke Health and Adjunct Professor, Medical University of South Carolina. Resick’s specialty is understanding and treating the effects of traumatic events, particularly posttraumatic stress disorder (PTSD). She developed cognitive processing therapy (CPT), considered a first-line therapy for PTSD, and has overseen multiple clinical trials. She has won research and mentoring awards as well as Lifetime Achievement Awards from three organizations.

Funding Statement

This article was funded in part by Consortium to Alleviate PTSD award numbers W81XWH-13-2-0065 from the U.S. Department of Defense, Defense Health Program, Psychological Health and Traumatic Brain Injury Research Program and I01CX001136-01 from the U.S. Department of Veterans Affairs, Office of Research & Development, Clinical Science Research & Development Service. Additional funding support was provided by the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program awards W81XWH-12-2-0073 (AL Peterson), W81XWH-13-2-0012 (PA Resick), W81XWH-13-2-0013 (AL Peterson), and W81XWH-15-1-0391 (DM Sloan).

Competing Interests

The views expressed herein are solely those of the authors and do not reflect an endorsement by or the official policy or position of the U.S. Army, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government.

Ethics Approval

Ethics approval was not required for this article.

Informed Consent

N/A

Registry and Registration No. of the Study/Trial

N/A

Animal Studies

N/A

Peer Review

This article has been peer reviewed.

References

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