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. Author manuscript; available in PMC: 2018 Nov 1.
Published in final edited form as: Psychol Trauma. 2017 Apr 27;9(6):672–678. doi: 10.1037/tra0000282

Does Combat Exposure Affect Well-being in Later Life?

The VA Normative Aging Study

Hyunyup Lee 1, Carolyn M Aldwin 2, Soyoung Choun 3, Avron Spiro III 4
PMCID: PMC5659959  NIHMSID: NIHMS867202  PMID: 28447816

Abstract

Objective

Combat exposure has long-term negative effects in later life, and aspects of service may be appraised positively, but the long-term effects of combat on well-being in later life is largely unknown.

Method

The sample included 1,006 male veterans from the VA Normative Aging Study, surveyed by mail in 1986, 1990, and 1991 (Mage = 62.5, SD = 7.27). They reported on their combat exposure, desirable appraisals of military service, unit cohesion, dispositional optimism, self-rated health, and psychological well-being (PWB), as well as age, military rank, and education. Perceived positive aspects (PPA) of military service was postulated to mediate the effects of combat exposure on PWB. SEM was used to examine both mediating and moderating effects.

Results

Age, combat exposure, and optimism had independent effects on PPA, but optimism did not moderate the effect of combat exposure on PPA. Combat exposure had only indirect effects on PWB through the PPA, controlling for the direct effects of optimism. Education had no direct effects on the positive outcomes, but did have indirect effects through optimism.

Conclusion

Combat exposure contributes to positive well-being in later life, indirectly through positive appraisals, and this effect was independent of optimism. Thus, these results support the idea that combat veterans should be encouraged to focus on positive aspects of military service, which may serve as resilience resources to facilitate optimal aging.

Keywords: Combat exposure, Optimism, Perceived positive aspects of military service, Psychological well-being, Aging

The extensive experience of American men in military service and combat has drawn researchers' attention to the relationship between combat exposure as a traumatic stressor and its consequent outcomes in later life, i.e., midlife and late life. Thus, military service (including combat exposure) has been described as the “hidden variable” in research on aging (Spiro, Schnurr, & Aldwin, 1997). About 16 million US soldiers served in the military during World War II, 1.8 million were deployed to the Korean peninsula during the Korean War, and 3.4 million were deployed to Southeast Asia during the Vietnam War. After the all-volunteer force (AVF) was introduced in 1973, about 0.7 million served in the Gulf War, and 2.5 million were deployed during the Afghanistan and Iraq Wars (U.S. Census Bureau, 2013). As of 2010, there were nearly 23 million veterans alive in the United State, most of whom (40%) were 65 years of age or older, and approximately 34% of these veterans had combat exposure (U.S. Department of Veterans Affairs, 2010).

Combat exposure can give rise to both negative and positive outcomes (Aldwin, Levenson, & Spiro, 1994; Spiro, Settersten, & Aldwin, 2016). However, the focus of most research has been on the negative consequences of combat exposure (Fulton et al., 2015; Kang, Aldwin, Choun, & Spiro, 2016). The positive effects of combat exposure are less known, with the exception of a few studies that have shown simple associations among relevant factors. For example, some studies have shown that veterans recognize positive aspects of military service (Aldwin, et al., 1994; Jennings, Aldwin, Levenson, Spiro, & Mroczek, 2006) and experience posttraumatic growth (PTG) after captivity experience (Feder et al., 2008). Thus, even traumatic combat exposure can be associated with positive outcomes, but the process through which this occurs is poorly understood. The purpose of this study is to examine several possible pathways through which combat exposure could affect positive well-being in later life. In particular, we hypothesize that positive appraisals of military service and unit cohesion will mediate this relationship, controlling for personality factors (optimism), demographics, and health.

Combat Exposure and Positive Consequences

As indicated above, there have been a few studies examining the effect of combat exposure on positive outcomes. Combat veterans reported higher levels of coping skills and value of life (Aldwin et al., 1994; Aldwin & Levenson, 2005; Elder & Clipp, 1989), less psychological distress on the Minnesota Multiphasic Personality Inventory (Schnurr, Rosenberg, & Friedman, 1993), and higher unit cohesion (Brailey, Vasterling, Proctor, Constans, & Friedman, 2007). In addition, Gallaway, Millikan, and Bell (2011) demonstrated that soldiers who reported moderate or high level of combat exposure had much higher PTG than those who reported low level of combat exposure. Solomon and Dekel (2007) noted that prisoners of war (POWs) had higher level of PTG compared to veterans who had no POW experience.

Other studies have also indicated non-significance or inverse relationships between combat exposure and positive outcomes. For example, combat exposure did not have significant relationship with PTG (Maguen, Vogt, King, King, & Litz, 2006; Marotta-Walters, Choi, & Shaine, 2015; Pietrzak et al., 2010). Research comparing eudaimonic (meaning-related) well-being among three different groups varying in combat exposure, found that combat veterans did not differ from non-combat veterans and non-veterans in psychological well-being, despite their higher levels of stress (Aldwin, Park, Choun, & Lee, in press). On the other hand, combat veterans with posttraumatic stress disorder (PTSD) who were recruited from residential patients and outpatient had lower daily self-esteem compared to non-PTSD veterans, only 9% of whom had combat exposure (Kashdan, Uswatte, & Julian, 2006).

These differing results may be due to the disparate measurements of positive outcomes and sample types. For example, the use of a specialized population, such as an Ivy League sample (Schnurr et al., 1993) or a specific Army brigade (Gallaway et al., 2011), might enhance the strength of the positive associations. Moreover, desirable appraisals and unit cohesion as positive aspects of the military service were relatively consistent (Aldwin et al., 1994; Kang et al., 2016), but PTG or psychological well-being of veterans in later life varied depending on the types of veteran groups that were compared (Aldwin et al., in press; Solomon & Dekel, 2007) and the inclusion of other demographic and psychosocial covariates (Feder et al., 2008; Tsai, Sippel, Mota, Southwick, & Pietrzak, 2016). Thus, more work is needed to identify the relationships among combat exposure and positive consequences in a general veteran sample, as well as to differentiate perceived positive aspects of military service and psychological well-being in later life.

Few studies have examined possible pathways to positive development in the combat exposure context. In a longitudinal study, Marotta-Walters et al. (2015) found that combat exposure did not have a positive relationship with PTG, but rather there was an indirect effect through negative psychosocial development, with PTSD positively related to combat exposure and PTG. While negative psychosocial development was associated with PTG, the effect of positive development on salutary outcome in later life is unclear, and suggests that more research needs to be done on the positive pathway.

Thus, the current study focuses on the positive pathway and hypothesizes that combat exposure is associated with perceived positive aspects including desirable appraisals and unit cohesion, based on previous work (Kang et al., 2016). In turn, these effects are hypothesized to mediate between combat exposure and psychological well-being in later life. Psychological well-being can be understood as having two different aspects: hedonic well-being, which is based on happiness or pleasure such as positive affect and life satisfaction, and eudaimonic well-being, which is related to pursuing meaning in life and personal growth (Ryan & Deci, 2001; Ryff, 1989). Veterans have shown relatively consistent negative or null outcomes in terms of hedonic well-being in later life. For example, veterans with combat exposure showed lower life satisfaction and positive affect, but higher depressive symptoms and negative affect than veterans without combat exposure (Aldwin et al., in press), and combat exposure did not predict life satisfaction (Seligowski et al., 2012). As discussed above, however, eudaimonic well-being needs to be investigated further, given the divergent results reviewed earlier. For this reason, the current study focused on the eudaimonic aspect of psychological well-being.

The Importance of Optimism

It is likely that personality traits influence both the perception of the positive aspects of military service, as well as psychological well-being in later life. In this sense, dispositional optimism, a relatively stable tendency to expect favorable outcomes, is well known for promoting psychological well-being (Carver, Scheier, & Segerstrom, 2010; Uskul & Greenglass, 2005). Studies in military populations have found that optimism was an important predictor of psychological and physical health of prisoners of war (Segovia, Moore, Linnville, & Hoyt, 2015) and combat veterans (Achat, Kawachi, Spiro, Demolles, & Sparrow, 2000). Thus, it is highly likely that optimism influences positive outcomes for veterans such as perceived positive aspects of military service and psychological well-being.

On the other hand, it is possible that there may be psychological well-being among veterans independent of the effect of optimism. For example, Tsai et al. (2016) compared dispositional optimism between veterans who maintained higher PTG and those who had lower PTG. They found no significant difference in optimism between the groups, supporting the idea that psychological well-being could be independent of optimism. Moreover, to our knowledge, no one has examined whether optimism might moderate the impact of stress on positive outcomes, such as the perceived positive aspects of military service.

Covariates

Positive outcomes in the aftermath of combat exposure can be influenced by rank (Dechter & Elder, 2004; Gallaway et al., 2011), age (Feder et al., 2008), education (Vogt, King, King, Savarese, & Suvak, 2004), and self-rated health (Wilmoth, London, & Parker, 2010). Education has an especially close relationship with mental health (Uskul & Greenglass, 2005), and provides a lifelong advantage for successful aging (Meeks & Murrell, 2001). Veterans who had higher education reported lower PTSD (McNally & Shin, 1995) and better life satisfaction (Vogt et al., 2004). On the other hand, Reed and Carstensen (2012) argued that older people tend to recall more positive than negative information, compared to younger people. Thus, it is possible that positive outcomes of veterans could be influenced by age.

Self-rated health is also a covariate, as it is affected by combat status among veterans (Aldwin et al., in press), declines with age (Wilmoth et al., 2010), and predicts psychological well-being even after 35 years (Friedman, Kern, & Reynolds, 2010). Individuals high in optimism often report better physical health (Carver et al., 2010), although, to our knowledge, there are no studies of optimism and self-reported health among veterans.

Although military rank, age, education, and self-rated health are often covariates in military research, we found no studies that investigated the relationships among optimism, demographic factors, and psychological outcomes in veterans.

Present Study

We examined the effects of combat exposure and optimism on well-being in later life in two ways. First, combat exposure and optimism were utilized as predictors of positive outcomes, considering the role of optimism as a control for reporting bias in the effect of combat exposure on positive outcomes. That is, does combat exposure lead to positive outcomes, controlling the effect of optimism as well as other covariates? Second, optimism was analyzed as a moderator between combat exposure and perceived positive aspects of military service. In other words, are individuals who are higher in optimism more likely to report positive outcomes in the face of combat exposure? Figure 1 depicts the pathways through which combat exposure might influence perceived positive aspects of military service, which in turn, are hypothesized to affect psychological well-being in later life. Optimism was hypothesized as influencing both positive outcomes and moderating the effect of combat exposure on positive aspects of military experience. Lastly, we included self-rated health in the model to adjust for its influence on both mediators and outcomes. In the current study, combat exposure, perceived positive aspects, and psychological well-being were analyzed as latent factors.

Figure 1.

Figure 1

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Conceptual model for the effects of combat exposure and optimism on positive outcomes.

Methods

Sample and Procedure

The sample consisted of male veterans participating in the VA Normative Aging Study (NAS), a longitudinal study that began in the 1960s (Spiro & Bossé, 2001). Over 6,000 men were recruited and screened for absence of serious chronic, physical, and mental disease from 1961 – 1970, and 2,280 were enrolled (Bossé, Ekerdt, & Silbert, 1984). NAS men received health examinations every three years, and are sent mail surveys periodically. Data for the present study were gleaned from four mail surveys. Most of the variables were drawn from the Military Experience Survey in 1990 and a short follow-up survey in 1991 (Aldwin et al., 1994). Psychological well-being, self-rated health, and optimism were assessed in 1991. Education came from a survey conducted in 1986. Our sample consists of 1,006 men and their mean age in 1991 was 65.5 (SD = 7.3, range = 47 – 92). Most NAS men (92%) were veterans who served during World War II or the Korean War; these two cohorts did not differ in education, occupational category, marital status, and life satisfaction (Spiro, Schnurr, & Aldwin, 1994). Most participants were white (98%) and 86% were married. Among them, 38% were high school graduates and 62% were college graduates.

Measures

Combat exposure

Combat exposure assesses the severity of exposure to combat and its effects. This was assessed using Keane et al.'s (1989) 7-item Combat Exposure Scale (CES), with items rated on a 5-point Likert scale (e.g., “Were you ever under enemy fire?”). (1= Never done, 5 = Over 7). Scores were adjusted following Keane et al. (1989), and items were weighted according to frequency or severity. Each item measures different types of combat exposure (e.g., experience of combat patrol, being surrounded by the enemy fire, and so on). For this reason, exploratory factor analysis (EFA) was conducted using Mplus (Muthén & Muthén, 2012). EFA, using geomin rotation, yielded a one-factor solution, based on the eigenvalues and the scree plot. Thus, all items were used as manifest indicators for the latent factor, combat exposure (for measurement model information, see online Appendix A).

Perceived positive aspects of military service

Perceived positive aspects include four variables: self-development, values, skills, and unit cohesion. Desirable appraisals of military service have been used to assess the positive aspects for military experience (Elder & Clipp, 1989; Aldwin et al., 1994); 14 items were rated on a 4-point Likert scale (1 = not at all to 4 = a lot). Aldwin and Levenson (2005) identified three factors using a sample of British veterans.

We computed an EFA to examine the factor structure and found three factors (Table 1): (1) self-development (e.g., “greater self-discipline”); (2) values (e.g., “value life more”); and (3) skills (e.g., “better job skills and options”). We used unit weightings to compute scores on the three subscales, distributing items based on the EFA (Cronbach's αs = .89, .83, and .68).

Table 1. Exploratory Factor Analysis of the Desirable Military Experiences Scale.
Factor loadings
Self - development Values Skills
A broader perspective on things .73
Learned to cope with adversity .88
Greater self-discipline, dependability .90
Became more independent .80
Positive feeling about self .43
Lifelong friends .32
Value life more .58
Became proud to be an American .68
Clearer direction and purpose in life .53 .38
Rewarding memories .33
Learned cooperation, teamwork .36 .42
Appreciate peace more .79
Improved life chances through education .44
Better job skills and options .67
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Note. Loadings for each factor item are in boldface; double loaders were assigned to the factor with the higher loadings.

Model fit indicators: χ = 404.14, df = 52, RMSEA = .08, CFI = .95, TLI = .92, SRMR = .028.

Unit cohesion was measured by three questions assessing veterans' attitudes toward the military in terms of sense of belonging to unit, service mates, and armed service. Three items were scored using a 7-point Likert scale in which higher scores indicate higher cohesion (e.g., “How did you get along with your service mates?”) (1 = disliked everyone to 7 = excellent relations) (Cronbach's α = .71).

Thus, perceived positive aspects was a latent factor with four indicators: self-development, values, skills, and unit cohesion (for measurement model analyses, see online Appendix A).

Psychological well-being

We assessed psychological well-being (Ryff, 1989) in the 1991 Social Support Survey. Twenty items were rated on a 5-point Likert scale (e.g., “I feel I am in charge of the situation in which I live”) (0 = strongly disagree to 4 = strongly agree). This scale consists of four sub-scales: autonomy, personal growth, purpose in life, and mastery. Each subscale has 5 items (Cronbach's αs = .61, .67, .75, and .76); subscales were used as manifest indicators for the latent factor, psychological well-being (for measurement model analyses, see online Appendix A).

Optimism

We assessed optimism in the same survey, utilizing 8 items from Scheier and Carver's (1985) 12-item scale (the 4 filler items were omitted). Items were rated on a 5-point Likert scale (e.g., “I always look on the bright side of things”) (0 = strongly disagree to 4 = strongly agree). Score were summed such that higher scores indicated higher levels of optimism (Cronbach's α = .79).

Covariates

Age, education, military rank, and self-rated health were utilized as covariates. Age and education were assessed in years. Most veterans were enlisted at entry (89.3%), with a small portion of noncommissioned officers (NCOs; 3.5%) and commissioned officers (5.4%). We dichotomized military rank (0 = Enlisted, 1 = NCOs and Officers). Self-rated health was assessed on a 5-point Likert scale (1 = very poor to 5 = excellent).

Analyses

We computed descriptive statistics and correlations for all manifest indicators and covariates. We used Mplus, Version 7.0 (Muthén & Muthén, 2012) for all analyses, including EFA, confirmatory factor analysis (CFA), and structural equation modeling (SEM) analysis, with the moderating analysis and the bootstrap analysis (using 1000 samples) to examine the mediating effect or indirect effects (see online Appendix A for the CFA details). Model fit was evaluated using various goodness of fit indices, including Root Mean Square Error of Approximation (RMSEA; Kline, 2005), Standardized Root Mean Square Residual (SRMR; Hu & Bentler, 1999), Comparative Fit Index (CFI; Brown, 2015), and Tucker-Lewis Index (TLI; Brown, 2015). Missing data on the study variables ranged from 1.6% - 8.6%. In order to produce unbiased parameter estimates and standard errors while retaining as much data as possible, we used full information maximum likelihood (FIML) robust estimation (Schafer & Graham, 2002).

Results

Descriptive Statistics and Correlations Among Study Variables

Age was positively correlated with military rank and all aspects of combat exposure, reflecting the fact that the older NAS men were more likely to be in combat, particularly WWII veterans. (for correlations, means, and standard deviations among study variables, see online Appendix B). Age was also associated with values and unit cohesion in the perceived positive aspects of military service, but was inversely associated with self-development, personal growth, and purpose in life. Education was also positively associated with military rank, but was inversely correlated with many of the combat exposure indicators, and with values and unit cohesion. However, education was positively correlated with most of the well-being and optimism measures. Military rank showed a slight relationship with only one indicator of psychological well-being, purpose in life. Thus, we omitted military rank from the multivariate analyses.

Optimism was unrelated to age, but was significantly associated with education and military rank. Additionally, optimism was only weakly associated with some of the recollections of combat exposure. It was significantly but weakly associated with the perceived positive aspects of military service, and was moderately to strongly associated with the psychological well-being indicators.

As expected, the indicators of combat exposure were highly intercorrelated, as were the perceived positive aspects and psychological well-being measures. The perceived positive aspects of military service were also positively correlated with the combat exposure indicators, and they were also positively correlated with the psychological well-being measures. Self-rated health was weakly associated with age, education, and the perceived positive aspects of military service, but was unrelated to combat exposure. Not surprisingly, the correlations were stronger with optimism and psychological well-being.

The Effects of Combat Exposure and Optimism on Positive Outcomes

We first tested the moderating effect of optimism on perceived positive aspects of military service. Contrary to the hypothesis, optimism did not moderate the effect of combat on perceptions of positive aspects of military service, B = -.003, p = .705. Thus, we revised the model, omitting the moderating effect of optimism. The final model included the mediating effect of positive aspects of military service (combat exposure → perceived positive aspects → psychological well-being), controlling the effects of optimism, age, and education on the two positive outcomes (Figure 2). The final model fit the data well: χ2(120) = 497.61, RMSEA = .06, CFI = .95, TLI = .94, SRMR = .04.

Figure 2.

Figure 2

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Final model for the effects of combat exposure and optimism on positive outcomes. Only significant pathways between variables are displayed.

Note. * p < .05. **p < .01. ***p < .001.

As indicated in Figure 2, combat exposure was positively associated with age, and negatively associated with education. Controlling for the effects of optimism and age, combat exposure was significantly associated with perceived positive aspects of military service, β = .23, p < .001, but there was no direct effect on psychological well-being, β = .04, p = .226. However, combat exposure had an indirect effect on psychological well-being through its influence on the positive aspects of military service, β = .02, p = .016, 95% CI [.004, .04], which supports our hypothesis that the impact of combat exposure on psychological outcome is mediated through perceived positive aspects.

Although optimism did not moderate the effect of combat exposure on perceived positive aspects, it was significantly associated with both perceived positive aspects and psychological well-being. Both combat exposure and optimism were independent predictors of perceived positive aspects. Education had no direct relationship with either positive aspects of military service or psychological well-being. Instead, education was positively associated with optimism, which in turn was significantly associated with both of the positive outcomes. We tested the indirect effects of education through optimism, and found significant indirect effects to both the perceived positive aspects of military service (education → optimism → perceived positive aspects), β = .03, p = .001, 95% CI [.01, .05], and the psychological well-being (education → optimism → psychological well-being), β = .13, p < .001, 95% CI [.09, .18]. When we added self-reported health to the model, the direct and indirect effects changed little, and comparison of the model fit indices showed that the model omitting self-reported health provided a better fit to the data, ΔX2 (Δ df = 12) = 21.19, p < .05.

Discussion

The aim of this study was to examine the effects of combat exposure and optimism on the appraisal of the positive aspects of military service and well-being in later life, that is, middle age and late life. Our results demonstrated that combat exposure had significant direct effects on the perceived positive aspects of military service, consistent with previous studies in this sample (Aldwin et al., 1994; Kang et al., 2016). However, there was no direct effect of combat exposure on psychological well-being in later life; rather, there was an indirect effect of combat exposure mediated by perceived positive aspects of military service. This implies that veterans who viewed their service as having positive aspects were more likely to report better well-being in later life. Note that this effect was independent of optimism, suggesting that the effect is not simply a reporting bias.

Spiro et al. (2016) developed a model of the long-term outcomes of military service in which combat exposure can lead to positive as well as negative outcomes, depending on coping strategies and generalized resistance resources such as personality. The current study buttresses this lifespan model by demonstrating one positive pathway, providing evidence that combat exposure, mediated by positive appraisals, can lead to better well-being in later life.

Optimism was significantly related to both positive appraisals of military service and well-being in later life, consistent with prior research (Achat et al., 2000; Segovia et al., 2015). Contrary to our hypothesis, it did not moderate the effect of combat exposure on positive aspects of military service. Veterans with greater dispositional optimism reported higher levels of well-being in later life, regardless of combat exposure. Nonetheless, there were independent positive effects of combat exposure on the appraisals of the positive aspects of military service.

Positive reappraisal is strongly associated with posttraumatic growth in the aftermath of traumatic experience such as cancer and natural disaster (Prati & Pietrantoni, 2009). Thus, this research supports efforts to encourage combat veterans to focus more on positive aspects of military service, such as positive reappraisal when facing challenges or adversities, that may serve as resilience resources (Cornum, Matthews, & Seligman, 2011). Settersten, Aldwin, and Spiro (in press) suggested that providing veterans with greater resilience resources would keep them from developing PTSD and could facilitate optimal aging. Thus, perceived positive aspects of military service could be a critical resource for resilience of veterans with traumatic combat exposure.

In addition, we found an unhypothesized but interesting result: education did not have a direct effect on either appraisals of military service or well-being in later life, but rather had indirect effects, mediated through optimism. Others have found that education has a positive impact on mental health (McNally & Shin, 1995; Uskul & Greenglass, 2005), so we were not surprised by this finding. It appears that the beneficial effect of education may be through its impact on optimism. It should be remembered that optimism involves the cognitive expectations of favorable outcomes in the future (Carver et al., 2010), and education might well increase an individual's sense of mastery and thus result in higher optimism (e.g., Daraei & Ghaderi, 2012).

There are several limitations to this study. First, this study used cross-sectional, retrospective data on military service, and causality cannot be assumed. It is possible that individuals with higher levels of well-being in later life were more likely to remember and appraise their prior experiences in a positive light (Reed & Carstensen, 2012). Thus, there may be a recall bias and reporting bias. However, because optimism was only weakly associated with the perceived positive aspects of military service, there may have been only a limited positivity bias. Nevertheless, future studies should focus more on changes in positive outcomes across time, using longitudinal data, to accurately examine the lifelong effects of combat exposure.

Second, perceived positive aspects of military service and psychological well-being may have similar features in that both concepts are related with positive thinking. However, psychological well-being (or eudaimonic well-being) emphasizes living life in a full and deeply satisfying way, typically focusing on purpose, mastery, meaning of life, and religion/spirituality (Ryan & Deci, 2001). On the other hand, perceived positive aspects of military service focus on reappraisals of a particular set of stressful experiences, indicating a tendency to reframe stressful events as beneficial (Lazarus & Folkman, 1984). Although the current study established the indirect effect of combat exposure on psychological well-being via positive appraisals independent of optimism, future study needs to replicate the salutary effects of combat exposure utilizing other positive outcomes such as PTG and mediating effects of positive appraisals in the relationships.

Third, the current study only dealt with combat exposure and adjusted only for the effects of optimism, health, age, and education. Other variables, such as social support from family and community, or government programs, may be key covariates of psychological growth (Pietrzak & Southwick, 2011; Southwick et al., 2016). Moreover, veterans who experience age-related challenges such as loss of loved ones and jobs in later life may engage in later-adulthood trauma re-engagement (LATR), having successfully dealt earlier in life with the trauma related to combat exposure (Davison et al., 2016). Thus, more research is needed to understand the net effects of combat exposure on positive outcomes, controlling for other potential factors that would influence positive consequences such as relationships with family members or friends and job/retirement-related issues.

Finally, the sample was all male and largely white and middle class, which limits generalizability to women and other ethnic groups. In particular, the number of women veterans increased from 2% of troops stationed in Vietnam war to 10% in OEF/OIF (Murdoch et al., 2006), and it is known there are differences in the number of trauma between male and female veterans (Cohen et al., 2016). Thus, it will be worth examining how or if the combat exposure differently influences veterans depending on gender.

In summary, combat exposure can have positive impacts on aspects of military service, including unit cohesion, independent of age, health, education, or optimism. Determining ways of enhancing these positive effects of even terrible experiences will better enable us to increase resilience to trauma.

Supplementary Material

1

Acknowledgments

This research was supported by grants from the National Institute on Aging (R29-07465, R01-AG032037, and R24-AG039343), by VA Merit Reviews and a Senior Research Career Scientist Award from the US Department of Veterans Affairs, and by a doctoral training grant from the Korea Army Headquarters. The views expressed in this paper are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the Korea Military Academy.

Contributor Information

Hyunyup Lee, Oregon State University.

Carolyn M. Aldwin, Oregon State University

Soyoung Choun, Oregon State University.

Avron Spiro, III, Veterans Affairs Health Care System, Boston University Schools of Medicine & Public Health.

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